Genotype- or Phenotype-Based Drug Formulations

ABSTRACT

The invention relates to a combination of two or more pharmaceutically active substances, of which at least one is a metabolic product (“metabolite”) of the other (“parent substance”), wherein in particular the dosages thereof are selected such that genotypically or phenotypically related variability in the conversion of the parent substance to the metabolite in particular individuals is compensated for.

The invention relates to a combination of two or more pharmaceuticallyactive substances, of which at least one is a metabolic product(“metabolite”) of the other (“parent substance”), in particular thedosages thereof are selected such that genotypically or phenotypically(definition of genotype http://de.wikipedia.org/wiki/Genotyp, definitionof phenotype: http://de.wikipedia.org/wiki/Ph%C3%A4notyp) relatedvariability in the conversion of the parent substance to themetabolite(s) in particular individuals is compensated for. Theinvention further relates to a combination of two or morepharmaceutically active substances, of which at least one is a metabolicproduct of the other, and the dosages thereof are selected such thatgenotypically or phenotypically related variability in transporters,receptors or other proteins involved in pharmacokinetic orpharmacodynamic processes of the parent substance and of themetabolite(s) in particular individuals is compensated for.

The principle according to the invention will be illustrated using theexample of the combination of the breast cancer medicament tamoxifen andits active metabolite endoxifen.

In pharmacotherapy, there are numerous examples of pharmaceuticals, thepharmacological action of which arises from the interplay of theadministered parent substance with metabolites which develop in the bodyof the patient. Such so-called active metabolites are generally formedvia enzymatically catalysed processes, which can take place in, forexample, the liver, the kidneys, the intestine or any other organ of thebody. The activity of these enzymatic processes can widely differ indifferent individuals. The reasons for enzyme activities differing fromindividual to individual are diverse in nature. Firstly, there areindividual variations in the quantity of the expressed enzyme variantswhich can be brought about by, for example, enzyme inhibitors orinducers or else genetic causes. Secondly, there are individualvariations in the activity of the expressed enzyme variants which canoccur owing to, for example, enzyme inhibitors or inducers or elsegenetic causes. Many active pharmaceutical ingredients are knowncytochrome P450 enzyme inhibitors, for example:

-   -   2-(4-chlorophenoxy)ethanol, acarbose, acebutolol, acenocoumarol,        acetazolamide, adefovir, ademetionine, ajmaline, albendazole,        alitretinoin, allopurinol, alosetron, ambroxol, amphetamine,        amiloride, aminoglutethimide, aminophenazone, amiodarone,        amitriptyline, amlodipine, amodiaquine, amprenavir, anastrozole,        androstandolone, aprepitant, aripiprazole, arsenic trioxide,        artemisinin, artesunate, astemizole, atazanavir, atomoxetine,        atorvastatin, atovaquone, atropine, azapropazone, azelastine,        azithromycin, barnidipine, benazepril, benidipine,        benzbromarone, benzethonium, benzocaine, bergapten,        betamethasone, betaxolol, bezafibrate, bicalutamide, bifonazole,        biperiden, bortezomib, bromazepam, bromocriptine,        brompheniramine, budipine, buprenorphine, buproprion,        calcitriol, candesartan, capecitabine, carbamazepine,        carbinoxamine, carteolol, caspofungin, celecoxib, cerivastatin,        quinidine, quinine, chloramphenicol, chlormadinone, chloroquine,        chlorphenamine, chlorpromazine, chlorzoxazone, ciclosporin,        cimetidine, ciprofibrate, ciprofloxacin, cisapride, cisplatin,        citalopram, clarithromycin, clemastine, clevidipine,        clindamycin, clobetasol, clofazimine, clofenotane, clofibrate,        clomethiazole, clomifene, clomipramine, clonazepam, clopidogrel,        clotiazepam, clotrimazole, clozapine, cocaine, codeine,        caffeine, colchicine, colecalciferol, cyclizine,        cylcophosphamide, cyproterone, dacarbazine, dactinomycin,        dalfopristine, danazol, dantrolene, daunorubicin, deferoxamine,        delarvirdine, desipramine, desloratadine, desvenlafaxine,        dexamethasone, dexamfetamine, dexfenfluramine, dexibuprofen,        dextrometorphan, dextropropoxyphene, diazepam, diclofenac,        dicoumarol, dihydralazine, dihydroergotamine,        diiodohydroxypropane, diltiazem, dimethyl sulphoxide,        dimetotiazine, diosmectite, diosmin, diphenhydramine,        disulfiram, docetaxel, dolasetron, dopamine, doxepin,        doxorubicin, doxycycline, ebastine, econazole, efavirenz,        emetine, enoxacin, enoxolone, enprostil, entacapone, epinastine,        epinephrine, eplerenone, eprosartan, ergometrine, ergotamine,        erythromycin, escitalopram, estriol, etanautine, ethanol,        ethinylestradiol, ethotoin, etodolac, etomidate, etoposide,        etoricoxib, etretinate, exemestane, ezetimibe, felbamate,        felodipine, fenfluramine, fenofibrate, fentanyl, fexofenadine,        flecainide, flumequine, fluorouracil, fluoxetine, fluphenazine,        flurazepam, flurbiprofen, flurithromycin, flutamide,        fluvastatin, fluvoxamine, fomepizole, formestane, fosamprenavir,        fosphenytoin, gefitinib, gemfibrozil, glibenclamide, gliclazide,        glucose, glutethimide, granisetron, g-strophanthin,        halofantrine, haloperidol, histamine, hydralazine,        hydrocortisone, hydroxycarbamide, hydroxychloroquine,        hydroxyzine, ibuprofen, idarubicin, ifosfamide, imatinib,        imipramine, indinavir, indometacin, insulin, ipriflavone,        irbesartan, irinotecan, isoconazole, isoflurane, isoniazid,        isoprenaline, isopropanol, isosorbide dinitrate, isradipine,        itraconazole, josamycin, ketoconazole, ketoprofen, labetalol,        lafutidine, lansoprazole, leflunomide, lentinan, lercarnidipine,        letrozole, levofloxacin, levomepromazine, levonorgestrel,        lidocaine, lomefloxacin, lomustine, loperamide, lopinavir,        loratadine, lornoxicam, losartan, lovastatin, manidipine,        masoprocol, meclozine, medazepam, medroxyprogesterone,        medrysone, mefenamic acid, mefloquine, meglutol, melatonin,        meloxicam, melperone, memantine, menadione, mephenytoin,        mequitazine, mesuximide, metamfetamine, metformin, methadone,        methazolamide, methoxsalen, methylphenidate,        methylphenobarbital, methylprednisolone, metoclopramide,        metoprolol, metronidazole, metyrapone, mexiletine, mianserin,        mibefradil, miconazole, midazolam, midecamycin, midodrine,        mifepristone, minoxidil, miocamycin, mirtazapine, mitoxantrone,        mizolastine, moclobemide, modafinil, mometasone, montelukast,        moracizine, nefazodone, nelfinavir, neostigmine, nevirapine,        nicardipine, niclosamide, nicotinamide, nifedipine, nicotine,        nicotic acid, nilutamide, nilvadipine, nimesulide, nisoldipine,        nitrendipine, nitroprusside, norepinephrine, norfloxacin,        nortriptyline, noscapine, octopamine, ofloxacin, olanzapine,        oleandomycin, omeprazole, ondansetron, orphenadrine,        oxamniquine, oxatomide, oxcarbazepine, oxprenolol, oxybutynin,        oxycodone, paclitaxel, pancreozymin (cholecystokinin),        pantoprazole, paracetamol, parecoxib, pargyline, paroxetine,        pazopanib, pefloxacin, pentoxyverin, perazine, pergolide,        perhexiline, perphenazine, phenazone, phenelzine, phenobarbital,        phensuximide, phentermine, phenylbutazone, phenylpropanolamine,        phenytoin, physostigmine, pilocarpine, pimozide, pindolol,        pioglitazone, piroxicam, pranlukast, prasterone, pravastatin,        praziquantel, prednisolone, prednisone, primaquine,        pristinamycin, probenecid, progesterone, proguanil,        promethazine, propafenone, propanol, propiverine, propofol,        propranolol, pyrimethamine, quassia, mercury, quetiapine,        quinidine, quinine, quinupristin, rabeprazole, raloxifene,        ranitidine, reboxetine, retinol, rifampicin, risperidone,        ritonavir, rivastigmine, rofecoxib, rokitamycin, ropinirole,        rosiglitazone, rosuvastatin, roxithromycin, rutoside,        salbutamol, salicylamide, salmeterol, saquinavir, selegiline,        seratrodast, sertaconazole, sertraline, sildenafil, silymarin,        simvastatin, sirolimus, somatostatin, sorbitol, sparteine,        spironolactone, nitrogen monoxide, sulconazole, sulfadiazine,        sulfadimethoxine, sulfadimidine, sulfafurazole, sulfamethizole,        sulfamethoxazole, sulfamoxole, sulfanilamide, sulfaphenazole,        sulfapyridine, sulfinpyrazone, sulindac, sulpiride, suprofen,        tacrolimus, tamoxifen, tegaserod, telithromycin, telmisartan,        temafloxacin, teniposide, tenofovir, terbinafine, terconazole,        terfenadine, teriparatide, testosterone, tetracycline,        theophylline, thiamazole, thiopental, thioridazine,        thiosulphate, thiotepa, tiabendazole, tibolone, ticlopidine,        timolol, tinidazole, tioconazole, tiopronin, tiotixen,        tocainide, tocopherol, tofisopam, tolbutamide, tolcapone,        topiramate, topotecan, torasemide, tramadol, tranylcypromine,        trastuzumab, treosulfan, tretinoin, triamterene, triazolam,        trichloroethylene, triclosan, trimethoprim, tripelennamine,        triprolidine, troglitazone, troleandomycin, tropisetron,        trospium, ursodeoxycholic acid, valdecoxib, valproic acid,        valsartan, venlafaxine, verapamil, vinblastine, vincristine,        vinorelbine, virginiamycin, voriconazole, vorozole, warfarin,        yohimbine, zafirlukast, ziprasidone, zolpidem, zonisamide.

Particular emphasis is given here to: fluvoxamine, ciprofloxacin,gemfibrozil, bupropion, cinacalcet, fluoxetine, paroxetine, quinidine,indinavir, nelfinavir, ritonavir, clarithromycin, itraconazole,ketoconazole, nefazodone, saquinavir, telithromycin, trimethoprim,amiodarone, duloxetine, sertraline, terbinafine, aprepitant,erythromycin, verapamil, diltiazem, cimetidine, amiodarone[http://medicine.iupui.edu/clinpharm/ddis/table.aspx as of May 9, 2012].

Known inhibitors of phase 2 enzymes are, inter alia:

-   -   acarbose, acetylcholine, acetylsalicylic acid, amitriptyline,        apomorphine, artemisinin, ascorbic acid, bendroflumethiazide,        bergapten, bromocriptine, carbachol, carbamazepine, carmustine,        celecoxib, chenodeoxycholic acid, quinine, chlorhexidine,        chloroquine, cimetidine, clomipramine, clonidine, cocaine,        cortisone, dactinomycin, desipramine, diazepam, dicoumarol,        dicycloverine, diosmin, disulfiram, doxepin, enoxolone,        entacapone, estradiol, etacrynic acid, fluconazole,        fluphenazine, folic acid, haloperidol, hematin, hydrocortisone,        hymecromone, ibuprofen, imipramine, indometacin, iproniazid,        ketoprofen, lidocaine, lopinavir, medroxyprogesterone,        melatonin, mepacrine, mercaptamine, mersalyl, mesalazine,        methyldopa, moclobemide, naproxen, sodium citrate, sodium        salicylate, niflumic acid, nicotine, olsalazine, oxedrine,        paclitaxel, pargyline, phenylbutazone, physostigmine,        pipamperone, polihexanide, primaquine, probenecid, progesterone,        propylthiouracil, pyridoxal, pyridoxine, pyrimethamine,        ranitidine, ritonavir, salicylamide, salicylic acid, saquinavir,        silymarin, sulphobromophthalein, sulindac, tacrine, tamoxifen,        tetracycline, thiomersal, tolcapone, triclosan, tubocurarine,        vecuronium, warfarin, hydrogen peroxide.

Examples of known cytochrome P450 enzyme inducers are:

-   -   2-(4-chlorophenoxy)ethanol, acarbose, acetylsalicylic acid,        acriflavinium chloride, albendazole, aldosterone, alum,        aminoglutetimide, aminosalicylic acid, amobarbital,        angiotensinamide, aprepitant, aprobarbital, aripiprazole,        artemisinin, ascorbic acid, azatidine, beclometasone,        benoxaprofen, beta-carotene, betamethasone, bexarotene,        bezafibrate, biotin, bosentan, bucladesine, buserelin,        captopril, carbamazepine, carbamide, carboplatin, quinidine,        quinine, chlordiazepoxide, chlorothiazide, chlorpromazine,        ciclosporin, ciprofibrate, ciprofloxacin, cisplatin, calcitriol,        clarithromycin, clofenotane, clofibrate, clomifen, clonazepam,        clonidine, clotrimazole, clozapine, colchicine, colestyramine,        corticotropin, cyclobarbital, cyclophosphamide, dapsone,        daunorubicin, dexamethasone, dextropropoxyphene, diazepam,        dibutyl phthalate, diclofenamide, dicloxacillin, dicycloverine,        diethyl ether, diethylstilbestrol, diiodohydroxypropane,        dinoprostone, diosmectite, diosmin, docetaxel, doxorubicin,        doxylamine, efavirenz, eletriptan, enoxacin, ergocalciferol,        erythromycin, estriol, ethanol, ethinylestradiol, etoposide,        fenbendazole, felbamate, fluconazole, flucloxacillin, flufenamic        acid, fluorescein, fluvastatin, gemfibrozil, glucose,        glutathione, glycerol, glycyrrhizic acid, granisetron,        griseofulvin, guanethidine, haloperidol, histamine,        hydrocortisone, hydroxycarbamide, ifosfamide, insulin,        ipriflavone, isoflurane, isoniazid, isoprenaline, isopropanol,        itraconazole, ketoconazole, cocaine, lansoprazole, lindane,        loratadine, lovastatin, lynestrenol, mebendazole, mecamylamine,        medroxyprogesterone, metamizole, methadone, metharbital,        methohexital, methylprednisolone, methyltestosterone,        metoclopramide, metyrapone, mifepristone, mirtazapine,        mitobronitol, mitomycin, mitotane, moclobemide, modafinil,        sodium chloride, sodium salicylate, nelfinavir, nevirapine,        nicardipine, nicotinamide, nifedipine, nicotine, nitrazepam,        norethisterone, omeprazole, ondansetron, oxcarbazepine,        oxiconazole, oxolamine, oxomemazine, paclitaxel, pantoprazole,        paracetamol, permethrin, pethidine, phenobarbital,        phenoxymethylpenicillin, phentermine, phenylbutazone,        phenylephrine, phenytoin, pindolol, pioglitazone, pipamperone,        pleconaril, prednisolone, prednisone, primaquine, primidone,        pristinamycin, probenecid, progesterone, propylthiouracil,        pyridostigmine, pyridoxine, mercury, quinine, rabeprazole,        reboxetine, reserpine, retinol, rifabutin, rifampicin,        rifapentine, rifaximin, ritonavir, rofecoxib, salicylic acid,        secobarbital, seratrodast, silymarin, spironolactone,        streptozocin, sulfadimidine, sulfinpyrazone, tamoxifen,        temozolomide, terbinafine, terfenadine, testosterone,        tetrabenazine, tetramethrin, thalidomide, thiamine, thiram,        tiabendazole, tienilic acid, tocopherol, topiramate, topotecan,        tretinoin, triamcinolone acetonide, triamcinolone, troglitazone,        tryptophan, ursodeoxycholic acid, valproic acid, verapamil,        vinblastine, virginiamycin, voglibose.

Particular emphasis is given here to: modafinil, nafcillin, omeprazole,phenobarbital, phenytoin, rifampin, secobarbital, carbamazepine,norethindrone, prednisone, rifampicin, dexamethasone, isoniazid,efavirenz, nevirapine, barbiturates, glucocorticoids, oxcarbazepine,pioglitazone, rifabutin, troglitazone[http://medicine.iupui.edu/clinpharm/ddis/table.aspx as of May 9, 2012].

The known inducers of phase 2 enzymes include, inter alia:

-   -   acetylcholine, acetylsalicylic acid, adenosine, amfetamine,        aminophylline, androstanolone, angiotensinamide, argatroban,        ascorbic acid, benfluorex, beta-carotene, betamethasone,        bucladesine, calcitriol, carbamazepine, chlorambucil,        chlorphenamine, cisapride, cisplatin, clofibrate, clozapine,        cocaine, corticotropin, desipramine, dexamethasone,        dexamfetamine, diazepam, diclofenac, diethylcarbamazine, diethyl        ether, dinoprostone, disulfiram, doxorubicin, entacapone,        epinephrine, esketamine, estradiol, estriol, ethanol,        flunarizine, fluoxetine, gabapentin, glyceryl trinitrate,        glycine, g-strophantin, hydralazine, hydrocortisone,        hymecromone, ibuprofen, imipramine, indometacin, insulin,        isoprenaline, ketamine, lamotrigine, levetiracetam, levodopa,        lindane, melatonin, melphalan, mequinol, metamizole, methionine,        methotrexate, metoclopramide, nabumetone, nandrolone,        norepinephrine, olanzapine, paracetamol, pargyline,        phenobarbital, phenytoin, pipamperone, progesterone,        promegestone, propylthiouracil, retinol, rofecoxib,        spironolactone, nitrogen monoxide, sulindac, sultiame,        tamoxifen, testosterone, theophylline, tiadenol, tibolone,        tioguanine, triamcinolone, trimethoprim, troglitazone, valproic        acid, verapamil, warfarin, hydrogen peroxide.

[http://bioinformatics.charite.de/supercyp as of Apr. 24, 2012]. Besidesactive pharmaceutical ingredients, dietary components may also haveinhibitory and/or inducing effects on enzymes, transporters, receptorsor other proteins.

Known examples thereof are, inter alia: broccoli, grilled meat, StJohn's wort, tobacco smoke, cheese, red wine, grapefruit juice, folicacid, vitamin K, vitamin E, vitamin B6 and St John's wort [Gröber, U.(2009) “Interaktionen Arzneimittel and Mikronährstoffe für dieKitteltasche [Interactions: Pharmaceuticals and Micronutrients (PocketGuide)]” Wissenschaftliche Verlagsgesellschaft mbH Stuttgart; Wentworth,J. M., M. Agostini, et al. (2000). “St John's wort, a herbalantidepressant, activates the steroid X receptor.” J Endocrinol 166(3):R11-16., http://medicine.iupui.edu/clinpharm/ddis/table.aspx as of May9, 2012]. Similar to the inducing effect of grilled meat on cytochromeP450 1A1 (CYP1A1), the enzyme can also be induced by polycyclicaromatics, which are present in cigarette smoke. For instance, it isdescribed in the literature that the activity of CYP1A1 in the lungs,liver and intestine of smokers is increased in proportion to theircigarette consumption Kzekaj, P., A. Wiaderkiewicz, et al. (2005).“Tobacco smoke-dependent changes in cytochrome P450 1A1, 1A2, and 2E1protein expressions in fetuses, newborns, pregnant rats, and humanplacenta.” Arch Toxicol 79(1): 13-24.; Fontana, R. J., K. S. Lown, etal. (1999). “Effects of a chargrilled meat diet on expression of CYP3A,CYP1A, and P-glycoprotein levels in healthy volunteers.”Gastroenterology 117(1): 89-98.; Kim, J. H., M. E. Sherman, et al.(2004). “Expression of cytochromes P450 1A1 and 1B1 in human lung fromsmokers, non-smokers, and ex-smokers.” Toxicol Appl Pharmacol 199(3):210-219., Pelkonen, O., M. Pasanen, et al. (1986). “The effect ofcigarette smoking on 7-ethoxyresorufin O-deethylase and othermonooxygenase activities in human liver: analyses with monoclonalantibodies.” Br J Clin Pharmacol 22(2): 125-134.; Zevin, S. and N. L.Benowitz (1999). “Drug interactions with tobacco smoking. An update.”Clin Pharmacokinet 36(6): 425-438.].

Furthermore, the pharmacological action of the parent substance and itsmetabolite(s) may also be dependent on the quantity or the activity ofexpressed protein variants, receptor variants or transporter variants,which may likewise greatly differ from individual to individual orwithin an individual owing to inhibition or induction or genetic causes.

Examples of transporter inducers are: dexamethasone, doxorubicin,flavonoids, St John's wort, phenobarbital, phenytoin, rifampicin,vinblastine.

Examples of transporter inhibitors are:

-   -   rifampicin, cyclosporin A, gemfibrozil, lopinavir, ritonavir,        clarithromycin, furosemide, indometacin, probenecid, naproxen,        ibuprofen, piroxicam, acetylsalicylic acid, paracetamol,        phenacetin, ketoprofen, enalapril, bumetanide, cefoperazone,        azathioprine, methotrexate, valproate, flufenamate,        phenylbutazone, levofloxacin, dexamethasone, cytarabine,        ampicillin, amoxicillin, ciclacillin, cephalexin, cefadroxil,        cephradine, cefdinir, ceftibuten, cefixime, captopril,        amiodarone, quinidine, lidocaine, itraconazole, ketoconazole,        diltiazem, felodipine, nicardipine, nifedipine, nitrendipine,        verapamil, indinavir, nelfinavir, saquinavir, ethinylestradiol,        norgestrel, progesterone, testosterone, tacrolimus,        erythromycin, mifepristone, paroxetine, talinolol, tamoxifen,        terfenadine, trifluoperazine, vincristine.

[Shitara, Y. (2011). “Clinical importance of OATP1B1 and OATP1B3 indrug-drug interactions.” Drug Metab Pharmacokinet 26(3): 220-227.; VanAubel, R. A., R. Masereeuw, et al. (2000). “Molecular pharmacology ofrenal organic anion transporters.” Am J Physiol Renal Physiol 279(2):F216-232.; http://www.pharmazeutische-zeitung.de/index.php?id=2381].

Of particular importance to pharmacotherapy are those differences inprotein activity which have a genetic cause. As a result of sequencevariations (http://de.wikipedia.org/wiki/Polymorphismus) in the allelesand/or as a result of a varying number of alleles present, it ispossible for different variants and/or quantities of a protein to beexpressed. Both, the expressed variant and the expressed quantity of aprotein, can have a strong influence on the activity of the proteinvariant.

In the literature, a well studied example of a polymorphic protein iscytochrome P450 2D6 (CYP2D6), an enzyme for which it is known that thereis a multiplicity of different gene variants which can be classifiedinto four different phenotypes. The customary designations for thispurpose are: PM=“poor metabolizer”, IM=“intermediate metabolizer”,EM=“extensive metabolizer” and UM=“ultrarapid metabolizer” Vanger, U.M., J. Fischer, et al. (2001). “Comprehensive analysis of the geneticfactors determining expression and function of hepatic CYP2D6.”Pharmacogenetics 11(7): 573-585.].

Besides CYP2D6, there are numerous other polymorphic enzymes from theclass of cytochrome P450 (CYP) isoenzymes:

-   -   CYP1A1, CYP1A2, CYP1B1, CYP2A6, CYP2A13, CYP2B6, CYP2C8, CYP2C9,        CYP2C11, CYP2C18, CYP2C19, CYP2D6, CYP2E1, CYP2F1, CYP2J2,        CYP2S1, CYP2W1, CYP3A4, CYP3A5, CYP3A7, CYP3A43, CYP4A11,        CYP4B1, CYP4F2, CYP4F22, CYP7A1, CYP4B1, CYP7B1, CYP8A1, CYP8B1,        CYP11A, CYP11B1, CYP11B2, CYP17A, CYP19A, CYP21A, CYP24A,        CYP26A1, CYP26B, CYP27A, CYP27B, CYP46A, CYP51A.

Particular emphasis is given here to: CYP1A2, CYP2B6, CYP2C8, CYP2C9,CYP2C19, CYP2D6, CYP2E1, CYP3A4, CYP3A5, CYP3A7[http://bioinformatics.charite.de/supercyp as of Apr. 24, 2012; Tamaki,Y., T. Arai, et al. (2011). “Association between cancer risk anddrug-metabolizing enzyme gene (CYP2A6, CYP2A13, CYP4B1, SULT1A1, GSTM1,and GSTT1) polymorphisms in cases of lung cancer in Japan.” Drug MetabPharmacokinet 26(5): 516-522.].

There are similarly numerous polymorphic phase 2 enzymes or otherenzymes in metabolism, for example:

-   -   N-acetyltransferase 2 (NAT2), thiopurine S-methyltransferase        (TPMT), uridine 5′-diphospho-glucuronosyltransferase (UGT) 1A1,        UGT1A3, UGT1A4, UGT1A5, UGT1A6, UGT1A7, UGT1A8, UGT1A9, UGT1A10,        UGT2A1, UGT2A2, UGT2A3, UGT2B4, UGT2B7, UGT2B10, UGT2B15,        UGT2B17, sulfotransferase (SULT) 1A1, SULT1A2, SULT1A3, SULT1E1,        SULT2A1, SULT2B1, SULT4A1, glutathione S-transferase (GST) A1,        GSTA2, GSTA3, GSTA4, GSTA5, GSTM1, GSTM2, GSTM3, GSTM4, GSTM5,        GSTP1, GSTT1, GSTT2, GSTO1, GSTO2, catechol-o-methyltransferase        (COMT), flavin-dependent monooxygenase 3 (FMO),        dihydropyrimidine dehydrogenase (DPD), methylenetetrahydrofolate        reductase (MTHFR).

Particular emphasis is given here to: NAT2, TPMT, UGT1A1, UGT1A4,UGT2B7, UGT2B15, SULT1A1, SULT1A2, SULT2A1, GSTM1, GSTP1, GSTT1, COMT,DPD, MTHFR [Hickman, D. and E. Sim (1991). “N-acetyltransferasepolymorphism. Comparison of phenotype and genotype in humans” BiochemPharmacol 42(5): 1007-1014.; Yates, C. R., E. Y. Krynetski, et al.(1997). “Molecular diagnosis of thiopurine S-methyltransferasedeficiency: genetic basis for azathioprine and mercaptopurineintolerance.” Ann Intern Med 126(8): 608-614.; Bernard, O., J. Tojcic,et al. (2006). “Influence of nonsynonymous polymorphisms of UGT1A8 andUGT2B7 metabolizing enzymes on the formation of phenolic and acylglucuronides of mycophenolic acid.” Drug Metab Dispos 34(9): 1539-1545.;Bushey, R. T., G. Chen, et al. (2011). “Characterization ofUDP-glucuronosyltransferase 2A1 (UGT2A1) variants and their potentialrole in tobacco carcinogenesis.” Pharmacogenet Genomics 21(2): 55-65.;Carlini, L. E., N. J. Meropol, et al. (2005). “UGT1A7 and UGT1A9polymorphisms predict response and toxicity in colorectal cancerpatients treated with capecitabine/irinotecan.” Clin Cancer Res 11(3):1226-1236.; Chen, G., A. S. Blevins-Primeau, et al. (2007).“Glucuronidation of nicotine and cotinine by UGT2B10: loss of functionby the UGT2B10 Codon 67 (Asp>Tyr) polymorphism.” Cancer Res 67(19):9024-9029.; Chen, G., R. W. Dellinger, et al. (2008). “Identification ofa prevalent functional missense polymorphism in the UGT2B10 gene and itsassociation with UGT2B10 inactivation against tobacco-specificnitrosamines.” Pharmacogenet Genomics 18(3): 181-191.; Chen, Y., S.Chen, et al. (2006). “Genetic variants of human UGT1A3: functionalcharacterization and frequency distribution in a Chinese Hanpopulation.” Drug Metab Dispos 34(9): 1462-1467.; Dellinger, R. W., J.L. Fang, et al. (2006). “Importance of UDP-glucuronosyltransferase 1A10(UGT1A10) in the detoxification of polycyclic aromatic hydrocarbons:decreased glucuronidative activity of the UGT1A10139Lys isoform.” DrugMetab Dispos 34(6): 943-949.; Guo, Y., C. Hu, et al. (2012). “Effects ofUGT1A6, UGT2B7, and CYP2C9 genotypes on plasma concentrations ofvalproic acid in Chinese children with epilepsy.” Drug MetabPharmacokinet.; He, X., L. M. Hesse, et al. (2009). “Evidence foroxazepam as an in vivo probe of UGT2B15: oxazepam clearance is reducedby UGT2B15 D85Y polymorphism but unaffected by UGT2B17 deletion.” Br JClin Pharmacol 68(5): 721-730.; Park, W. B., P. G. Choe, et al. (2010).“Genetic factors influencing severe atazanavir-associatedhyperbilirubinemia in a population with low UDP-glucuronosyltransferase1A1*28 allele frequency.” Clin Infect Dis 51(1): 101-106.; Parmar, S.,J. C. Stingl, et al. (2011). “Impact of UGT2B7 His268Tyr polymorphism onthe outcome of adjuvant epirubicin treatment in breast cancer.” BreastCancer Res 13(3): R57.; Saeki, M., Y. Saito, et al. (2004). “Singlenucleotide polymorphisms and haplotype frequencies of UGT2B4 and UGT2B7in a Japanese population.” Drug Metab Dispos 32(9): 1048-1054.; Sneitz,N., M. H. Court, et al. (2009). “Human UDP-glucuronosyltransferaseUGT2A2: cDNA construction, expression, and functional characterizationin comparison with UGT2A1 and UGT2A3.” Pharmacogenet Genomics.; Sun, D.,G. Chen, et al. (2006). “Characterization of tamoxifen and4-hydroxytamoxifen glucuronidation by human UGT1A4 variants.” BreastCancer Res 8(4): R50.; Swanson, C., D. Mellstrom, et al. (2007). “Theuridine diphosphate glucuronosyltransferase 2B15 D85Y and 2B17 deletionpolymorphisms predict the glucuronidation pattern of androgens and fatmass in men.” J Clin Endocrinol Metab 92(12): 4878-4882.; Yang, J., L.Cai, et al. (2012). “Genetic Variations and Haplotype Diversity of theUGT1 Gene Cluster in the Chinese Population.” PLoS One 7(4): e33988.;Arslan, S. (2010). “Genetic polymorphisms of sulfotransferases (SULT1A1and SULT1A2) in a Turkish population.” Biochem Genet 48(11-12):987-994.; Hirata, H., Y. Hinoda, et al. (2008). “CYP1A1, SULT1A1, andSULT1E1 polymorphisms are risk factors for endometrial cancersusceptibility.” Cancer 112(9): 1964-1973.; Ji, Y., I. Moon, et al.(2007). “Human hydroxysteroid sulfotransferase SULT2B1 pharmacogenomics:gene sequence variation and functional genomics.” J Pharmacol Exp Ther322(2): 529-540.; Ramsey, T. L., H. Y. Meltzer, et al. (2011). “Evidencefor a SULT4A1 haplotype correlating with baseline psychopathology andatypical antipsychotic response.” Pharmacogenomics 12(4): 471-480.;Tamaki, Y., T. Arai, et al. (2011). “Association between cancer risk anddrug-metabolizing enzyme gene (CYP2A6, CYP2A13, CYP4B1, SULT1A1, GSTM1,and GSTT1) polymorphisms in cases of lung cancer in Japan.” Drug MetabPharmacokinet 26(5): 516-522.; Thomae, B. A., B. W. Eckloff, et al.(2002). “Human sulfotransferase SULT2A1 pharmacogenetics:genotype-to-phenotype studies.” Pharmacogenomics J 2(1): 48-56.; Thomae,B. A., O. F. Rifki, et al. (2003). “Human catecholamine sulfotransferase(SULT1A3) pharmacogenetics: functional genetic polymorphism.” JNeurochem 87(4): 809-819.; Breton, C. V., H. Vora, et al. (2009).“Variation in the GST mu locus and tobacco smoke exposure asdeterminants of childhood lung function.” Am J Respir Crit Care Med179(7): 601-607.; Chen, Y. L., H. S. Tseng, et al. (2010). “GlutathioneS-Transferase P1 (GSTP1) gene polymorphism increases age-relatedsusceptibility to hepatocellular carcinoma.” BMC Med Genet 11: 46.;Coles, B. F., F. Morel, et al. (2001). “Effect of polymorphism in thehuman glutathione S-transferase A1 promoter on hepatic GSTA1 and GSTA2expression.” Pharmacogenetics 11(8): 663-669.; Moyer, A. M., Z. Sun, etal. (2010). “Glutathione pathway genetic polymorphisms and lung cancersurvival after platinum-based chemotherapy.” Cancer Epidemiol BiomarkersPrev 19(3): 811-821.; Tetlow, N., M. Coggan, et al. (2004). “Functionalpolymorphism of human glutathione transferase A3: effects on xenobioticmetabolism and steroid biosynthesis.” Pharmacogenetics 14(10): 657-663.;Tran, A., F. Bournerias, et al. (2008). “Serious haematological toxicityof cyclophosphamide in relation to CYP2B6, GSTA1 and GSTP1polymorphisms.” Br J Clin Pharmacol 65(2): 279-280.; White, D. L., D.Li, et al. (2008). “Genetic variants of glutathione S-transferase aspossible risk factors for hepatocellular carcinoma: a HuGE systematicreview and meta-analysis.” Am J Epidemiol 167(4): 377-389.; Zhao, Y., M.Marotta, et al. (2009). “Linkage disequilibrium between twohigh-frequency deletion polymorphisms: implications for associationstudies involving the glutathione-S transferase (GST) genes.” PLoS Genet5(5): e1000472.; Motika, M. S., J. Zhang, et al. (2009). “Novel variantsof the human flavin-containing monooxygenase 3 (FMO3) gene associatedwith trimethylaminuria.” Mol Genet Metab 97(2): 128-135.; Voisey, J., C.D. Swagell, et al. (2011). “A novel SNP in COMT is associated withalcohol dependence but not opiate or nicotine dependence: a case controlstudy.” Behav Brain Funct 7: 51.; Fisher, M. C. and B. N. Cronstein(2009). “Metaanalysis of methylenetetrahydrofolate reductase (MTHFR)polymorphisms affecting methotrexate toxicity.” J Rheumatol 36(3):539-545.; Zhang, X. P., Z. B. Bai, et al. (2012). “Polymorphisms ofdihydropyrimidine dehydrogenase gene and clinical outcomes of gastriccancer patients treated with fluorouracil-based adjuvant chemotherapy inChinese population.” Chin Med J (Engl) 125(5): 741-746.].

There are also numerous examples of polymorphic transporters and/orreceptors and/or other proteins.

Examples of polymorphic transporters are:

-   -   ABCA1, ABCA2, ABCA3, ABCA4, ABCA7, ABCA8, ABCA12, ABCA13, ABCB1,        ABCB2, ABCB4, ABCB5, ABCB7, ABCB8, ABCB9, ABCB10, ABCB11, ABCC1,        ABCC2, ABCC3, ABCC4, ABCC5, ABCC6, ABCC8, ABCC9, ABCC10, ABCC11,        ABCD1, ABCD2, ABCD3, ABCD4, ABCe1, ABCF1, ABCG1, ABCG2, ABCG4,        ABCG5, ABCG8, OAT1, OAT2, OAT3, OAT4, URAT5, OATP1A2, OATP1B1,        OATP1B3, OATP1C1, OATP1B1, OCT1, OCT2, OCT3, OCTN1, OCTN2,        SLC22A16    -   [Akiyama, Y., K. I. Fujita, et al. (2011). “Association of ABCC2        genotype with efficacy of first-line FOLFIRI in Japanese        patients with advanced colorectal cancer.” Drug Metab        Pharmacokinet.; Fukao, M., K. Ishida, et al. (2011). “Effect of        genetic polymorphisms of SLC28A1, ABCG2, and ABCC4 on        bioavailability of mizoribine in healthy Japanese males.” Drug        Metab Pharmacokinet 26(5): 538-543.; Garcia-Donas, J., E.        Esteban, et al. (2011). “Single nucleotide polymorphism        associations with response and toxic effects in patients with        advanced renal-cell carcinoma treated with first-line sunitinib:        a multicentre, observational, prospective study.” Lancet Oncol        12(12): 1143-1150.; Hollingworth, P., D. Harold, et al. (2011).        “Common variants at ABCA7, MS4A6A/MS4A4E, EPHA1, CD33 and CD2AP        are associated with Alzheimer's disease.” Nat Genet 43(5):        429-435.; Iida, A., S. Saito, et al. (2002). “Catalog of 605        single-nucleotide polymorphisms (SNPs) among 13 genes encoding        human ATP-binding cassette transporters: ABCA4, ABCA7, ABCA8,        ABCD1, ABCD3, ABCD4, ABCE1, ABCF1, ABCG1, ABCG2, ABCG4, ABCG5,        and ABCG8.” J Hum Genet 47(6): 285-310.; Karadeniz, M., M.        Erdogan, et al. (2011). “Effect Of G2706A and G105 1A        polymorphisms of the ABCA1 gene on the lipid, oxidative stress        and homocystein levels in Turkish patients with polycystic ovary        syndrome.” Lipids Health Dis 10: 193.; Kelsell, D. P., E. E.        Norgett, et al. (2005). “Mutations in ABCA12 underlie the severe        congenital skin disease harlequin ichthyosis.” Am J Hum Genet        76(5): 794-803.; Knight, H. M., B. S. Pickard, et al. (2009). “A        cytogenetic abnormality and rare coding variants identify ABCA13        as a candidate gene in schizophrenia, bipolar disorder, and        depression.” Am J Hum Genet 85(6): 833-846.; Kwan, P., V. Wong,        et al. (2011). “Gene-wide tagging study of the association        between ABCC2, ABCC5 and ABCG2 genetic polymorphisms and        multidrug resistance in epilepsy.” Pharmacogenomics 12(3):        319-325.; Liptrott, N. J., S. Pushpakom, et al. (2012).        “Association of ABCC10 polymorphisms with nevirapine plasma        concentrations in the German Competence Network for HIV/AIDS.”        Pharmacogenet Genomics 22(1): 10-19.; Maia-Lopes, S., J.        Aguirre-Lamban, et al. (2009). “ABCA4 mutations in Portuguese        Stargardt patients: identification of new mutations and their        phenotypic analysis.” Mol Vis 15: 584-591.; Matsukawa, T., M.        Asheuer, et al. (2011). “Identification of novel SNPs of ABCD1,        ABCD2, ABCD3, and ABCD4 genes in patients with X-linked        adrenoleukodystrophy (ALD) based on comprehensive resequencing        and association studies with ALD phenotypes.” Neurogenetics        12(1): 41-50.; Minster, R. L., S. T. DeKosky, et al. (2009). “No        association of DAPK1 and ABCA2 SNPs on chromosome 9 with        Alzheimer's disease.” Neurobiol Aging 30(11): 1890-1891.;        Moitra, K., M. Scally, et al. (2011). “Molecular evolutionary        analysis of ABCB5: the ancestral gene is a full transporter with        potentially deleterious single nucleotide polymorphisms.” PLoS        One 6(1): e16318.; Pietrzak-Nowacka, M., K. Safranow, et al.        (2012). “Association of C49620T ABCC8 polymorphism with        anthropometric and metabolic parameters in patients with        autosomal dominant polycystic kidney disease: a preliminary        study.” Nefrologia 32(2): 153-159.; Saito, S., A. Lida, et al.        (2002). “Identification of 779 genetic variations in eight genes        encoding members of the ATP-binding cassette, subfamily C        (ABCC/MRP/CFTR.” J Hum Genet 47(4): 147-171.; Saito, S., A.        Iida, et al. (2002). “Three hundred twenty-six genetic        variations in genes encoding nine members of ATP-binding        cassette, subfamily B (ABCB/MDR/TAP), in the Japanese        population.” J Hum Genet 47(1): 38-50.; Sasaki, T., T. Hirota,        et al. (2011). “Systematic screening of human ABCC3        polymorphisms and their effects on MRP3 expression and        function.” Drug Metab Pharmacokinet 26(4): 374-386.; Schulz,        V., D. Hendig, et al. (2005). “Analysis of sequence variations        in the ABCC6 gene among patients with abdominal aortic aneurysm        and pseudoxanthoma elasticum.” J Vasc Res 42(5): 424-432.;        Shulenin, S., L. M. Nogee, et al. (2004). “ABCA3 gene mutations        in newborns with fatal surfactant deficiency.” N Engl J Med        350(13): 1296-1303.; Toyoda, Y. and T. Ishikawa (2010).        “Pharmacogenomics of human ABC transporter ABCC11 (MRP8):        potential risk of breast cancer and chemotherapy failure.”        Anticancer Agents Med Chem 10(8): 617-624.; Wasmuth, H. E., A.        Glantz, et al. (2007). “Intrahepatic cholestasis of pregnancy:        the severe form is associated with common variants of the        hepatobiliary phospholipid transporter ABCB4 gene.” Gut 56(2):        265-270.; Yin, J. Y., Q. Huang, et al. (2009). “Characterization        and analyses of multidrug resistance-associated protein 1        (MRP1/ABCC1) polymorphisms in Chinese population.” Pharmacogenet        Genomics 19(3): 206-216.; Yu, X., H. Xie, et al. (2011).        “Association of MDR1 gene SNPs and haplotypes with the        tacrolimus dose requirements in Han Chinese liver transplant        recipients.” PLoS One 6(11): e25933.; Lee, W., H. Glaeser, et        al. (2005). “Polymorphisms in human organic anion-transporting        polypeptide 1A2 (OATP1A2): implications for altered drug        disposition and central nervous system drug entry.” J Biol Chem        280(10): 9610-9617.; Mougey, E. B., H. Feng, et al. (2009).        “Absorption of montelukast is transporter mediated: a common        variant of OATP2B1 is associated with reduced plasma        concentrations and poor response.” Pharmacogenet Genomics 19(2):        129-138.; Trdan Lu 353 In, T., B. Stieger, et al. (2012).        “Organic anion transporting polypeptides OATP1B1 and OATP1B3 and        their genetic variants influence the pharmacokinetics and        pharmacodynamics of raloxifene.” J Transl Med 10(1): 76.; van        der Deure, W. M., P. S. Hansen, et al. (2008). “Thyroid hormone        transport and metabolism by organic anion transporter 1C1 and        consequences of genetic variation.” Endocrinology 149(10):        5307-5314.; Vormfelde, S. V., M. Schirmer, et al. (2006).        “Torsemide renal clearance and genetic variation in luminal and        basolateral organic anion transporters.” Br J Clin Pharmacol        62(3): 323-335.; Xu, G., V. Bhatnagar, et al. (2005). “Analyses        of coding region polymorphisms in apical and basolateral human        organic anion transporter (OAT) genes [OAT1 (NKT), OAT2, OAT3,        OAT4, URAT (RST)].” Kidney Int 68(4): 1491-1499.; Becker, M.        L., L. E. Visser, et al. (2011). “OCT1 polymorphism is        associated with response and survival time in anti-Parkinsonian        drug users.” Neurogenetics 12(1): 79-82., Lal, S., Z. W. Wong,        et al. (2007). “Novel SLC22A16 polymorphisms and influence on        doxorubicin pharmacokinetics in Asian breast cancer patients.”        Pharmacogenomics 8(6): 567-575., Park, T. J., J. H. Kim, et al.        (2011). “Possible association of SLC22A2 polymorphisms with        aspirin-intolerant asthma.” Int Arch Allergy Immunol 155(4):        395-402., Sakata, T., N. Anzai, et al. (2010). “Functional        analysis of human organic cation transporter OCT3 (SLC22A3)        polymorphisms.” J Pharmacol Sci 113(3): 263-266., Tahara,        H., S. W. Yee, et al. (2009). “Functional genetic variation in        the basal promoter of the organic cation/carnitine transporters        OCTN1 (SLC22A4) and OCTN2 (SLC22A5).” J Pharmacol Exp Ther        329(1): 262-271.]

Particular emphasis is given here to: ABCB1 (p-glycoprotein), ABCC1(MRP1), ABCG2 (BCRP), OATP1B1, OAT3, OCT1, OCT2, OCT3, SLC22A16.

In pharmacotherapy, such differences in enzyme activity or enzymequantity may have a dramatic influence on the success of treatment,since they directly influence the pharmacokinetics—and here inparticular the exposure—of the substances which are substrates for oneor more polymorphic enzymes and of the metabolite(s) formed by thepolymorphic enzyme. The same applies to such differences in proteinactivity or protein quantity, since receptors, transporters or otherproteins may also directly influence the pharmacokinetics—and here inparticular the exposure—of the substances which are substrates for oneor more polymorphic proteins. In addition, a direct effect on thepharmacodynamics may also occur here if these proteins are involved inthe mechanism of action.

There was therefore the need for improved pharmacotherapy in the use ofactive ingredients, the action of which is dependent on the quantity orthe activity of expressed and/or inhibited/induced protein variants,enzyme variants, receptor variants or transporter variants, with saidpharmacotherapy compensating for the aforementioned variations.

The present invention is based on a novel formulation concept, moreparticularly in the form of a fixed-dose combination (FDC), in whichpre-known individual differences in the activity of a relevant proteinare taken into consideration in the dosage of two or morepharmacologically active substances, of which one or more aremetabolites of the other substance, in order to ensure optimal successof treatment. The novel formulation concept is based on compensation ofthe varying exposure to the parent substance and one or more activemetabolites by a specific dosage of the combination of parent substanceand one/more metabolites that is individually adapted to the genotype orphenotype. The pharmacokinetic goal is to establish a“bioequivalence”-like steady-state situation (i.e. following repeatedintake), i.e. conformity of plasma concentration changes of theconcerned substances within predefined limits (for this purpose, it ispossible to use, for example, the criteria common in another context;see in this regard “Prior Art”), with respect to a reference populationwhich has to be defined from the specific context.

To study the formulation concept according to the invention,pharmacotherapy with tamoxifen was chosen as an example, withoutrestricting the concept to said example.

In the case of a CYP2D6 polymorphism, a population consisting ofextensive metabolizers (EMs) would be an example of a meaningfulreference population, since this phenotype represents the wild type andis the most widespread in many geographical regions [Sistonen, J., A.Sajantila, et al. (2007). “CYP2D6 worldwide genetic variation shows highfrequency of altered activity variants and no continental structure.”Pharmacogenet Genomics 17(2): 93-101.]. Using the example of a knowncancer medicament, tamoxifen, the problem of genotype- orphenotype-dependent exposure of active metabolites shall be illustratedwithout being restrictive thereto.

Tamoxifen is a well known pharmaceutical ingredient used for treatingoestrogen receptor-positive (ER+) breast cancer. The parent substance issubject to a complex metabolization scheme, which is shown in FIG. 1. Inthe human body (among others), tamoxifen is converted into three activemetabolites (N-desmethyltamoxifen, 4-hydroxytamoxifen, endoxifen). Amongthe active metabolites, endoxifen in particular, a secondary metaboliteof tamoxifen, is of importance, since a large percentage of theformation of endoxifen is catalysed via the polymorphic CYP2D6. As aresult, the endoxifen concentration in the blood of a breast cancerpatient is dependent on the CYP2D6 genotype or phenotype thereof. In thecase of a CYP2D6 PM, there is practically no CYP2D6 activity and theconcentration of the active metabolite endoxifen is consequently verylow Nurdter, T. E., W. Schroth, et al. (2011). “Activity levels oftamoxifen metabolites at the estrogen receptor and the impact of geneticpolymorphisms of phase I and II enzymes on their concentration levels inplasma.” Clin Pharmacol Ther 89(5): 708-717.; Jin, Y., Z. Desta, et al.(2005). “CYP2D6 Genotype, Antidepressant Use, and Tamoxifen MetabolismDuring Adjuvant Breast Cancer Treatment.” Journal of the National CancerInstitute 97(1): 30-39.; Gjerde, J., M. Hauglid, et al. (2008). “Effectsof CYP2D6 and SULT1A1 genotypes including SULT1A1 gene copy number ontamoxifen metabolism.” Ann Oncol 19(1): 56-61.; Borges, S., Z. Desta, etal. (2006). “Quantitative effect of CYP2D6 genotype and inhibitors ontamoxifen metabolism: implication for optimization of breast cancertreatment.” Clin Pharmacol Ther 80(1): 61-74.; Madlensky, L., L.Natarajan, et al. (2011). “Tamoxifen metabolite concentrations, CYP2D6genotype, and breast cancer outcomes.” Clin Pharmacol Ther 89(5):718-725.; Lim, J. S., X. A. Chen, et al. (2011). “Impact of CYP2D6,CYP3A5, CYP2C9 and CYP2C19 polymorphisms on tamoxifen pharmacokineticsin Asian breast cancer patients.” Br J Clin Pharmacol 71(5): 737-750.;Lim, H. S., H. Ju Lee, et al. (2007). “Clinical implications of CYP2D6genotypes predictive of tamoxifen pharmacokinetics in metastatic breastcancer.” J Clin Oncol 25(25): 3837-3845.; Kiyotani, K., T. Mushiroda, etal. (2010). “Significant effect of polymorphisms in CYP2D6 and ABCC2 onclinical outcomes of adjuvant tamoxifen therapy for breast cancerpatients.” J Clin Oncol 28(8): 1287-1293.; Irvin, W. J., Jr., C. M.Walko, et al. (2011). “Genotype-Guided Tamoxifen Dosing Increases ActiveMetabolite Exposure in Women With Reduced CYP2D6 Metabolism: AMulticenter Study.” J Clin Oncol 29(24): 3232-32391. In the case of aCYP2D6 IM, the endoxifen concentration is likewise still distinctlybelow the level which can observed in the case of an EM or the(relatively rare in Europeans) UM phenotype. In this connection, a studyalso showed a distinct gene dosage effect between CYP2D6 EM, IM, and PMgenotypes or phenotypes and their respective steady-state endoxifenconcentrations [Jin, Y., Z. Desta, et al. (2005). “CYP2D6 Genotype,Antidepressant Use, and Tamoxifen Metabolism During Adjuvant BreastCancer Treatment.” Journal of the National Cancer Institute 97(1):30-39]. The genotype- or phenotype-dependent exposures of endoxifen areshown by way of example in FIG. 2. Within a population of breast cancerpatients, the exposure of endoxifen is thus dependent on the frequencydistribution of the various CYP2D6 genotypes or phenotypes. Thisfrequency distribution differs greatly between regions or ethnic groups[Bernard, S., K. A. Neville, et al. (2006). “Interethnic differences ingenetic polymorphisms of CYP2D6 in the U.S. population: clinicalimplications.” Oncologist 11(2): 126-135.; Bradford, L. D. (2002).“CYP2D6 allele frequency in European Caucasians, Asians, Africans andtheir descendants.” Pharmacogenomics 3(2): 229-243.; Sachse, C., J.Brockmoller, et al. (1997). “Cytochrome P450 2D6 variants in a Caucasianpopulation: allele frequencies and phenotypic consequences.” Am J HumGenet 60(2): 284-295.; Sistonen, J., A. Sajantila, et al. (2007).“CYP2D6 worldwide genetic variation shows high frequency of alteredactivity variants and no continental structure.” Pharmacogenet Genomics17(2): 93-101.]. In the case of Europeans, EM is the predominantgenotype [Sistonen, J., A. Sajantila, et al. (2007). “CYP2D6 worldwidegenetic variation shows high frequency of altered activity variants andno continental structure.” Pharmacogenet Genomics 17(2): 93-101.].

There is now a range of studies which provides evidence for thedependency of the therapeutic success of tamoxifen on the CYP2D6genotype or phenotype Wijl, M., R. van Schaik, et al. (2009). “TheCYP2D6*4 polymorphism affects breast cancer survival in tamoxifenusers.” Breast Cancer Res Treat 118(1): 125-130.; Bonanni, B., D. Macis,et al. (2006). “Polymorphism in the CYP2D6 Tamoxifen-Metabolizing GeneInfluences Clinical Effect but Not Hot Flashes: Data From the ItalianTamoxifen Trial.” Journal of Clinical Oncology 24(22): 3708-3709.;Brauch, H., W. Schroth, et al. (2008). “Clinical Relevance of CYP2D6Genetics for Tamoxifen Response in Breast Cancer.” Breast Care (Basel)3(1): 43-50.; Brauch, H. B., W. Schroth, et al. (2011). “CYP2D6 andTamoxifen: Awaiting the Denouement.” Journal of Clinical Oncology29(34): 4589-4590.; Goetz, M. P., A. Kamal, et al. (2008). “Tamoxifenpharmacogenomics: the role of CYP2D6 as a predictor of drug response.”Clin Pharmacol Ther 83(1): 160-166.; Goetz, M. P., S. K. Knox, et al.(2007). “The impact of cytochrome P450 2D6 metabolism in women receivingadjuvant tamoxifen.” Breast Cancer Res Treat 101(1): 113-121.; Goetz, M.P., J. M. Rae, et al. (2005). “Pharmacogenetics of tamoxifenbiotransformation is associated with clinical outcomes of efficacy andhot flashes.” J Clin Oncol 23(36): 9312-9318.; Ingelman-Sundberg, M., S.C. Sim, et al. (2007). “Influence of cytochrome P450 polymorphisms ondrug therapies: pharmacogenetic, pharmacoepigenetic and clinicalaspects.” Pharmacol Ther 116(3): 496-526.; Newman, W. G., K. D.Hadfield, et al. (2008). “Impaired tamoxifen metabolism reduces survivalin familial breast cancer patients.” Clin Cancer Res 14(18): 5913-5918.;Schroth, W., L. Antoniadou, et al. (2007). “Breast cancer treatmentoutcome with adjuvant tamoxifen relative to patient CYP2D6 and CYP2C19genotypes.” J Clin Oncol 25(33): 5187-5193.; Schroth, W., M. P. Goetz,et al. (2009). “Association between CYP2D6 polymorphisms and outcomesamong women with early stage breast cancer treated with tamoxifen.” JAMA302(13): 1429-1436; Goetz, M. P., et al., CYP2D6 metabolism and patientoutcome in the Austrian Breast and Colorectal Cancer Study Group trial(ABCSG) 8. Clin Cancer Res, 2013. 19(2): p. 500-7.; Brauch, H., et al.,Tamoxifen Use in Postmenopausal Breast Cancer: CYP2D6 Matters. J ClinOncol, 20121. According to these studies, PMs consequently benefitdistinctly less from tamoxifen therapy than IMs, and these in turn lessthan EMs or UMs, and this is reflected, for example, in publishedrelapse-free survival curves (so-called Kaplan-Meier plots). Examples ofsuch published plots are shown in FIG. 3. In the past, these studyresults were interpreted to mean that the main action in breast cancertherapy with tamoxifen originates from its metabolite endoxifen(tamoxifen is occasionally also referred to in the literature as a“prodrug” [Goetz, M. P., A. Kamal, et al. (2008). “Tamoxifenpharmacogenomics: the role of CYP2D6 as a predictor of drug response.”Clin Pharmacol Ther 83(1): 160-166.]). Experts are also currentlydiscussing the proposal of whether endoxifen should not be directlyadministered instead of tamoxifen, and initial studies have beenpublished which have the goal of authorization of pure endoxifen as anagent for breast cancer therapy [Ahmad, A., S. M. Ali, et al. (2010).“Orally administered endoxifen is a new therapeutic agent for breastcancer.” Breast Cancer Res Treat 122(2): 579-584.; Ahmad, A., S.Shahabuddin, et al. (2010). “Endoxifen, a new cornerstone of breastcancer therapy: demonstration of safety, tolerability, and systemicbioavailability in healthy human subjects.” Clin Pharmacol Ther 88(6):814-817.].

Similarly, there have been discussions for some time among experts [deGraan, A. J., S. F. Teunissen, et al. (2011). “Dextromethorphan as aphenotyping test to predict endoxifen exposure in patients on tamoxifentreatment.” J Clin Oncol 29(24): 3240-3246.; Irvin, W. J., Jr., C. M.Walko, et al. (2011). “Genotype-Guided Tamoxifen Dosing Increases ActiveMetabolite Exposure in Women With Reduced CYP2D6 Metabolism: AMulticenter Study.” J Clin Oncol 29(24): 3232-3239.; Brauch, H., W.Schroth, et al. (2008). “Clinical Relevance of CYP2D6 Genetics forTamoxifen Response in Breast Cancer.” Breast Care (Basel) 3(1): 43-50.;Lim, J. S., X. A. Chen, et al. (2011). “Impact of CYP2D6, CYP3A5, CYP2C9and CYP2C19 polymorphisms on tamoxifen pharmacokinetics in Asian breastcancer patients.” Br J Clin Pharmacol 71(5): 737-750.] as to whetherpatients should not be genotyped or phenotyped prior to tamoxifentreatment in order to restrict administration to the EMs and UMs, whobenefit more (and so patients with the CYP2D6 PM and IM genotype orphenotype would have to manage without this inherently importanttreatment option). A further therapy strategy which is currently beingdiscussed is that of increasing the dose of tamoxifen on the basis ofgenotype or phenotype in order to achieve, in patients of the CYP2D6 IMand PM phenotype, similar endoxifen concentrations as are achieved inCYP2D6 EM patients under normal tamoxifen therapy. In this connection,one study shows that this approach might possibly be a solution forCYP2D6 IM patients, but for patients of the CYP2D6 PM phenotype,comparable concentrations of endoxifen were definitely not achieved.Consequently, this option is not conceivable for patients of the CYP2D6PM phenotype [Irvin, W. J., Jr., C. M. Walko, et al. (2011).“Genotype-Guided Tamoxifen Dosing Increases Active Metabolite Exposurein Women With Reduced CYP2D6 Metabolism: A Multicenter Study.” J ClinOncol 29(24): 3232-3239.].

According to the latest scientific knowledge, it has to be assumed thatthe positive action of tamoxifen in ER+ breast cancer can be attributedto the combination of the active components. Without doubt, tamoxifenitself has an anti-oestrogenic (and thus cancer-inhibiting) action, asdo the two primary metabolites 4-hydroxytamoxifen andN-desmethyltamoxifen, which would not circulate in the plasma of thepatient if endoxifen were administered, and it has to be assumed thatthe entire action of tamoxifen therapy is only achieved through theinterplay of the parent substance and its active metabolites [V. C.Craig, Long-Term Tamoxifen Treatment for Breast Cancer, S. 32, Allen, K.E., E. R. Clark, et al. (1980). “Evidence for the metabolic activationof non-steroidal antioestrogens: a study of structure-activityrelationships.” Br J Pharmacol 71(1): 83-91.; Kemp, J. V., H. K. Adam,et al. (1983). “Identification and biological activity of tamoxifenmetabolites in human serum.” Biochem Pharmacol 32(13): 2045-2052.].Consequently, it is doubtful whether exclusive endoxifen therapy can bea meaningful alternative to tamoxifen therapy; on the contrary, it hasto be assumed that sole endoxifen administration is not an appropriatemeasure against the CYP2D6-dependence of tamoxifen therapy in oestrogenreceptor-positive breast cancer.

The scientific prior art relating to tamoxifen therapy in breast canceris very well documented. Although it concerns a relatively oldsubstance, the CYP2D6 genotype- or phenotype-dependence of tamoxifentherapy is the subject of current research and lively discussions in thespecialist field.

There was therefore the specific need for a tamoxifen treatment whichtakes into account the CYP2D6 genotype or phenotype and which enablespatients of the CYP2D6 IM and PM phenotype to achieve endoxifenconcentrations similar to those achieved in CYP2D6 EM patients undernormal tamoxifen therapy and might accordingly also lead to promisingtherapy in the PMs and IMs in the form of breast cancer riskminimization.

To achieve the object, the present invention proposes combinedadministration of tamoxifen and endoxifen in a pharmaceuticalformulation, more particularly in a fixed-dose combination (FDC). In apreferred embodiment, the formulation according to the invention, moreparticularly the FDC, is dosed in a genotype- or phenotype-specificmanner.

FDCs consisting of two or more substances which are not related to oneanother like parent substance and metabolite are known according to theprior art and are, for example, used successfully in HIV therapy, type 2diabetes therapy, hypertension therapy, hyperlipidaemia therapy or inthe therapy of malaria and tuberculosis [Anvikar, A. R., B. Sharma, etal. (2012). “Artesunate-amodiaquine fixed dose combination for thetreatment of Plasmodium falciparum malaria in India.” Malar J 11(1): 97.Ayede, I. A., A. G. Falade, et al. (2010). “An open randomized clinicaltrial in comparing two artesunate-based combination treatments onPlasmodium falciparum malaria in Nigerian children:artesunate/sulphamethoxypyrazine/pyrimethamine (fixed dose over 24hours) versus artesunate/amodiaquine (fixed dose over 48 hours).” MalarJ 9: 378., Bramlage, P., W. P. Wolf, et al. (2010). “Effectiveness andtolerability of a fixed-dose combination of olmesartan and amlodipine inclinical practice.” Vasc Health Risk Manag 6: 803-811., Gadzhanova, S.,M. Gillies, et al. (2011). “Fixed dose combination diabetesmedicines—usage in the Australian veteran population.” Aust FamPhysician 40(10): 811-815., Honda, M., M. Ishisaka, et al. (2011).“Open-label randomized multicenter selection study of once dailyantiretroviral treatment regimen comparing ritonavir-boosted atazanavirto efavirenz with fixed-dose abacavir and lamivudine.” Intern Med 50(7):699-705., Kauf, T. L., K. L. Davis, et al. (2012). “Spillover adherenceeffects of fixed-dose combination HIV therapy.” Patient Prefer Adherence6: 155-164., Kim, S. H., K. H. Ryu, et al. (2011). “Efficacy offixed-dose amlodipine and losartan combination compared with amlodipinemonotherapy in stage 2 hypertension: a randomized, double blind,multicenter study.” BMC Res Notes 4: 461., Mathew, J. L. (2009). “Fixeddose drug combination for treatment of tuberculosis.” Indian Pediatr46(10): 877-880., Mengden, T., R. Hubner, et al. (2011). “Office andambulatory blood pressure control with a fixed-dose combination ofcandesartan and hydrochlorothiazide in previously uncontrolledhypertensive patients: results of CHILI CU Soon.” Vasc Health Risk Manag7: 761-769., Mengden, T., S. Uen, et al. (2009). “Management ofhypertension with fixed dose combinations of candesartan cilexetil andhydrochlorothiazide: patient perspectives and clinical utility.” VascHealth Risk Manag 5: 1043-1058., Okpechi, I. G., H. S. Schoeman, et al.(2011). “Achieving blood pressure goals sTudy in uncontrolledhypeRtensive pAtients treated with a fixed-dose combination oframipriL/hydrochlorothiazide: the ASTRAL study.” Cardiovasc J Afr 22(2):79-84., Reynolds, J. K. (2009). “Fixed-dose combination of sitagliptinand metformin for the treatment of type 2 diabetes.” Diabetes MetabSyndr Obes 2: 127-134., Shiga, Y., S. Miura, et al. (2011). “Comparisonof the efficacy and safety of single-pill fixed-dose combinations oflosartan/hydrochlorothiazide and valsartan/hydrochlorothiazide inpatients with hypertension (SALT-VAT study).” Intern Med 50(21):2477-2483.].

The advantages compared to separate administration of two or more activeingredients are the simpler logistics, the reduced costs in manufactureand distribution, and (crucial in the case of tamoxifen/endoxifen)improved compliance in the patients.

A fixed-dose combination, more particularly a genotype- orphenotype-specific FDC, containing a parent substance and one or morepotential metabolites and serving to compensate for genotype- orphenotype-related variability of the metabolite concentration is notknown according to the prior art. Similarly, a fixed-dose combinationcontaining a parent substance and one or more potential metabolites andserving to compensate for “phenotype-copying” related variability of themetabolite concentration is not known according to the prior art. Here,“phenotype-copying” means that, as a result of simultaneousadministration of one medicament which is converted into one/more activemetabolites via an enzyme and one potent enzyme inhibitor or enzymeinducer which inhibits or induces said conversion, the originalphenotype of the patient is converted into another on the basis of theinteraction between enzyme and enzyme inhibitor or enzyme inducer. Aplausible example here is the administration of a potent CYP2D6inhibitor (for example, paroxetine) to a patient of the CYP2D6 EMphenotype who is simultaneously receiving tamoxifen. As a result of theactive ingredient-mediated (for example, paroxetine) CYP2D6 inhibition,the original CYP2D6 EM patient is in effect an IM or PM and has,accordingly, lower endoxifen concentrations, the active secondarymetabolite of tamoxifen [Borges, S., Z. Desta, et al. (2006).“Quantitative effect of CYP2D6 genotype and inhibitors on tamoxifenmetabolism: implication for optimization of breast cancer treatment.”Clin Pharmacol Ther 80(1): 61-74.; Jin, Y., Z. Desta, et al. (2005).“CYP2D6 Genotype, Antidepressant Use, and Tamoxifen Metabolism DuringAdjuvant Breast Cancer Treatment.” Journal of the National CancerInstitute 97(1): 30-39., Stearns, V., M. D. Johnson, et al. (2003).“Active tamoxifen metabolite plasma concentrations aftercoadministration of tamoxifen and the selective serotonin reuptakeinhibitor paroxetine.” J Natl Cancer Inst 95(23): 1758-1764.].

Instead of breast cancer therapy purely with endoxifen, the approachinvolving a combined administration according to the invention oftamoxifen and endoxifen is advantageous in those patients who are notsufficiently able to form endoxifen (i.e. CYP2D6 PMs and IMs), owing tothe demonstrated efficacy of tamoxifen, N-desmethyltamoxifen and4-hydroxytamoxifen. The goal of such a combined administration should beto compensate for the genotype- or phenotype-related reduced formationof endoxifen by administration of an appropriate endoxifen dose and, atthe same time, to adapt the dose of tamoxifen if necessary such that PMsand IMs achieve steady-state plasma concentrations of tamoxifen,N-desmethyltamoxifen, 4-hydroxytamoxifen and endoxifen comparable to EMsor UMs under sole tamoxifen administration.

Beyond the aforementioned advantages of the tamoxifen-endoxifen FDCs forCYP2D6 IMs and PMs, application of the proposed fixed combination, moreparticularly 20 mg of tamoxifen and 3 mg of endoxifen, may also beadvantageous under certain circumstances in CYP2D6 EMs and IMs. Forexample, in the initial phase of tamoxifen therapy, the period untilattainment of the desired equilibrium concentration (also termedsteady-state concentration) can be considerably shortened. In the caseof the standard therapeutic dosage of 20 mg of tamoxifen, thesteady-state concentration of endoxifen in an example populationconsisting of European patients of the CYP2D6 EM genotype or phenotypeis achieved after about 80 days [Fabian C, Sternson L, El-Serafi M, CainL, Hearne E.; Clinical pharmacology of tamoxifen in patients with breastcancer: correlation with clinical data. Cancer. 1981 Aug. 15;48(4):876-82.; Jin Y, Desta Z, Stearns V, Ward B, Ho H, Lee K H, SkaarT, Storniolo A M, Li L, Araba A, Blanchard R, Nguyen A, Ullmer L, HaydenJ, Lemler S, Weinshilboum R M, Rae J M, Hayes D F, Flockhart D A.;CYP2D6 genotype, antidepressant use, and tamoxifen metabolism duringadjuvant breast cancer treatment. J Natl Cancer Inst. 2005 Jan. 5;97(1):30-9.; Fuchs W S, Leary W P, van der Meer M J, Gay S, WitschitalK, von Nieciecki A.; Pharmacokinetics and bioavailability of tamoxifenin postmenopausal healthy women. Arzneimittelforschung. 1996 April;46(4):418-22.]. By contrast, if the tamoxifen therapy is initiallycarried out with the proposed fixed combination, it is shown, on thebasis of the PBPK model, that the effective steady-state concentrationsof endoxifen appear distinctly faster, viz. after just 9 days, as shownin FIGS. 11 and 12.

The advantages of the fixed tamoxifen-endoxifen combination that areshown for the start of breast cancer therapy with tamoxifen can, inaddition, also be transferred to the frequently occurring real-lifesituation of continuous medicament intake being interrupted (alsoreferred to as non-compliance). Such non-compliance is known intamoxifen patients and well documented. Poor compliance is associatedwith a possible poorer response to tamoxifen therapy [Barron, T. I., etal., Early discontinuation of tamoxifen: a lesson for oncologists.Cancer, 2007. 109(5): p. 832-9.; Dezentje, V. O., et al., Effect ofconcomitant CYP2D6 inhibitor use and tamoxifen adherence on breastcancer recurrence in early-stage breast cancer. J Clin Oncol, 2010.28(14): p. 2423-9.; Friese, C. R., et al., Adjuvant endocrine therapyinitiation and persistence in a diverse sample of patients with breastcancer. Breast Cancer Res Treat, 2013.; Hershman, D. L., et al., Earlydiscontinuation and nonadherence to adjuvant hormonal therapy in acohort of 8,769 early-stage breast cancer patients. J Clin Oncol, 2010.28(27): p. 4120-8.; McCowan, C., et al., Cohort study examiningtamoxifen adherence and its relationship to mortality in women withbreast cancer. Br J Cancer, 2008. 99(11): p. 1763-8.; Partridge, A. H.,Non-adherence to endocrine therapy for breast cancer. Ann Oncol, 2006.17(2): p. 183-4.; Rae, J. M., et al., Cytochrome P450 2D6 activitypredicts discontinuation of tamoxifen therapy in breast cancer patients.Pharmacogenomics J, 2009. 9(4): p. 258-64.; Ruddy, K. J. and A. H.Partridge, Adherence with adjuvant hormonal therapy for breast cancer.Ann Oncol, 2009. 20(3): p. 401-2; Ziller, V., et al., Adherence toadjuvant endocrine therapy in postmenopausal women with breast cancer.Ann Oncol, 2009. 20(3): p. 431-6.].

In the event of a tamoxifen drug holiday, the plasma levels of tamoxifenand its active metabolites (thus, endoxifen too in particular) fallbelow the therapeutically effective threshold. Similar to the initialtamoxifen therapy, the fixed combination can likewise be advantageouslyused here in CYP2D6 EMs and IMs in order to speed up the renewedattainment of effective concentrations, as shown by the results of thesimulations in FIGS. 15 to 18.

Therefore, the present invention firstly provides a pharmaceuticalformulation containing a parent substance, the action of which isdependent on the quantity or the activity of expressed and/orinhibited/induced protein variants, enzyme variants, receptor variantsor transporter variants, and one or more potential metabolites of theparent substance. In particular, the dosage of the formulation accordingto the invention is defined in a genotype- or phenotype-specific manner.

However, such a combined formulation of multiple pharmaceutically activesubstances is associated with difficulties. The main difficulty is thatof determining the optimal endoxifen and tamoxifen dose which ensuresthe therapeutically effective steady-state plasma levels in CYP2D6 PMsand IMs.

In the present invention, this further object was, by way of example,achieved by means of a method based on the use of a coupledphysiologically based pharmacokinetic (PBPK) model for tamoxifen,4-hydroxytamoxifen, N-desmethyltamoxifen and endoxifen. Said method andthe corresponding commercially available model PK-Sim®/MoBi® aredescribed in the applications WO2007/147539, WO05/116854 and WO05/033982, the teachings of which are hereby integrated in this respect,and are used in the present invention to develop a method based on acoupled PBPK model. The development of the coupled PBPK model fortamoxifen, N-desmethyltamoxifen, 4-hydroxytamoxifen and endoxifen inCYP2D6 EMs and PMs has already been described [Dickschen, K., et al.,Physiologically-based pharmacokinetic modeling of tamoxifen and itsmetabolites in women of different CYP2D6 phenotypes provides new insightinto the tamoxifen mass balance. Frontiers in Pharmacology, 2012. 3.].The method was subsequently used, by way of example, to optimize thetamoxifen and endoxifen doses in CYP2D6 PMs and IMs. The only differencebetween the published CYP2D6 PM model parameterization and the CYP2D6 IMparameterization additionally presented here is the factor used forCYP2D6 enzyme activity (IM: 0.62; PM 0.015 Koller, J. K., N.Krebsfaenger, et al. (2002). “The influence of CYP2B6, CYP2C9 and CYP2D6genotypes on the formation of the potent antioestrogenZ-4-hydroxy-tamoxifen in human liver.” Br J Clin Pharmacol 54(2):157-167.1). FIG. 4 shows a diagram of the coupled PBPK model fortamoxifen and its three active metabolites (N-desmethyltamoxifen,4-hydroxytamoxifen, endoxifen).

Therefore, the present invention further provides a method for preparinga fixed-dose combination pharmaceutical formulation comprising a parentsubstance, the action of which is dependent on the amount or theactivity of expressed and/or inhibited/induced protein variants, enzymevariants, receptor variants or transporter variants, and at least onemetabolite of the parent substance, comprising the following steps:

-   -   a) inputting of an organism, of its genotype or phenotype, of        the parent substance and at least the metabolite of the parent        substance, of an optimal reference steady-state plasma level for        the parent substance for a reference genotype or reference        phenotype in the case of delivery of the parent substance alone        into an input module,    -   b) forwarding of the data from a) into a calculation module        comprising a substance data module, an organism data module, a        genotype data module or a phenotype data module, and a        physiologically based pharmacokinetic model, wherein the        substance data module comprises data concerning the        physicochemical and/or biochemical properties of the        substance(s), the organism module comprises data concerning the        compartments of the organism, and the genotype data module or        phenotype data module comprises genotype- or phenotype-specific        data,    -   c) automatically selecting parent substance and        metabolite-specific data from the substance data module,    -   d) automatically selecting organism-specific data from the        organism data module on the basis of input a),    -   e) automatically selecting genotype- or phenotype-specific data        from the genotype data module or phenotype data module,    -   f) forwarding of the selected data from a) to e) into the        physiologically based pharmacokinetic model,    -   g) calculating, by means of the physiologically based        pharmacokinetic model, an optimized dosage for the parent        substance for the reference genotype or reference phenotype in        order to attain the inputted optimal reference plasma level for        the parent substance from a),    -   h) calculating the reference steady-state plasma level for the        metabolites (N-desmethyltamoxifen, 4-hydroxytamoxifen,        endoxifen) for the reference genotype or reference phenotype in        the case of administration of the dose of parent substance        calculated in g),    -   i) calculating a plasma level of the metabolite(s) that is        reduced owing to the genotype or phenotype inputted in a) with        respect to the corresponding reference plasma level in the case        of administration of the dose of parent substance calculated in        g),    -   j) calculating a metabolite dose and a parent substance dose for        the combined attainment of the reference plasma level for the        metabolite(s) from h) and of the reference plasma level for the        parent substance from a),    -   k) outputting the metabolite dose and the parent substance dose        for the fixed-dose combination pharmaceutical formulation via an        output module, and/or    -   l) forwarding the dose calculated in j) into an automated device        for dosing medicaments.

In the present invention, automated devices for dosing medicaments meandevices for preparing dosage forms such as, for example, tablets,capsules, liquid dosage or elements thereof, and also apparatuses formeasuring out the dosage, such as a balance, unit-dose systems known inthe prior art, or a device for volumetrically or gravimetricallymeasuring out liquids.

Optionally, the calculation module additionally has an administrationmodule which comprises data concerning dosage forms such as, forexample, tablets, capsules, liquid dosage, or elements thereof. Saiddata usually comprise release properties of the dosage form, such asimmediate, delayed release and also differentiated (e.g. by means of alayered active-ingredient distribution) or simultaneous release (e.g. bymeans of joint granulation) for combination formulations. In the inputmodule, the dosage form can then be selectively defined, and the dataconcerning the corresponding dosage form are automatically selected fromthe administration module and forwarded to the physiologically basedpharmacokinetic model.

The calculation module calculates the optimal medicament dose for theparent substance and the metabolite(s) and, where appropriate, anoptimal dosing regimen. It consists of computer-implemented software andthe hardware required to execute the program. The hardware is generallya commercially available PC. It is either directly connected to an inputdevice, as in the case of a laptop computer with a built-in keyboard orchip card reader, or set up locally and connected to the input device(server). In principle, all common transmission technologies, bothcable-based and wireless methods, are suitable and conceivable.Particularly preferred is wireless transmission of the patientinformation inputted via the handheld input module or the chip cardreader.

The software makes it possible to manage all information relevant tocalculating the optimal medicament dosage in one or more databases. In apreferred embodiment of the method, it is also possible to carry out thecalculation of a patient-specific dose. This information relevant tocalculating the medicament dose is usually divided intoorganism-specific, substance-specific, genotype- or phenotype-specificand preferably administration-specific data, and preferably stored,automatically retrievable, in corresponding data modules.

In a preferred embodiment which is particularly relevant to personalizedmedication, physiological (or anthropometric) information, pathologicalinformation, possibly information relating to additionally administeredmedicaments, so-called co-medication, are also likewise stored,automatically retrievable, in date modules as patient-specific data.

The substance data include, for example, lipophilicity, free plasmafraction, blood-plasma ratio, partition coefficients, permeability,volume of distribution, clearance, nature of the clearance, clearanceproportions, nature of the excretion, dosing regimen, transportersubstrate, pharmacokinetic and/or pharmacodynamic end-point and adverseeffects.

Relevant medicament information is, more particularly, the recommendedtherapeutic dosage (according to information from the manufacturer),pharmacokinetic and/or pharmacodynamic end-point, clearance (totalclearance as blood or plasma clearance in a reference population or areference individual) and nature of the clearance (hepatic-metabolic,biliary, renal, etc.) and the proportions of the individual processeswith respect to the total clearance, kinetic parameters of activetransporters/receptors/enzymes if the medicament and/or itsmetabolite(s) is substrate for one or more activetransporters/receptors/enzymes, and physicochemical and pharmacokineticinformation such as, for example, lipophilicity, unbound fraction inplasma, plasma proteins to which the medicament and/or its metabolite(s)binds, blood-plasma distribution coefficient, or volume of distribution.

Empirical knowledge which, for example, can be obtained through theresearch of case studies can likewise additionally be part of thedatabases with substance information or information relating toco-medication.

Analogous to patient-specific information, relevant physiological oranthropometric and pathophysiological information is, for example, ineach case age, gender, race, weight, height, body mass index, lean bodymass, fat-free body mass, gene expression data, diseases, allergies,medication, renal function and hepatic function. Relevantpathophysiological information is, more particularly, diseases,allergies, renal function and hepatic function.

In the case of co-medication, the corresponding aforementionedinformation concerning all additional administered medicaments is partof the database relating to the co-medication.

The optimal dosage and, where appropriate, the optimal dosing regimenare calculated on the basis of the substance-specific data,organism-specific data and genotype- or phenotype-specific data possiblycombined with the administration-specific data using a rationalmathematical model for calculating the pharmacokinetic andpharmacodynamic behaviour of the substances to be administered (parentsubstance and metabolite(s)) on the basis of the information present inthe databases. In this connection, rational mathematical models can, forexample, be allometric scaling functions or physiologically basedpharmacokinetic models.

In a preferred embodiment of the invention, a physiologically basedpharmacokinetic/pharmacodynamic simulation model is used to calculatethe individual dosage. Particularly preferred is the dynamicallygenerated physiologically based simulation model described in detail inWO2005/633982.

A particular advantage when using the physiologically based simulationmodel from WO2005/633982 is the possibility of dynamically simulatingsimultaneous administration of multiple medicaments and theirinteraction. In this connection, dynamically means that, in theinteraction, the kinetics of the two (possibly, also, more than two)interacting substances can be taken into consideration. This isadvantageous over a static consideration in which, for example, anenzyme or a transporter is completely or partly inhibited in atime-independent manner, since the dynamic simulation allowsoptimization of the dosing regimen. A possible result of suchoptimization of the dosing regimen is, for example, the maintenance of amaximum interval of, for example, 12 hours (for a once dailyadministration) when administering two interacting substances in orderto minimize the mutual influence.

Particularly suitable for carrying out the method according to theinvention is the systems biology software suite consisting of PK-Sim®and MoBi® from Bayer Technology Services GmbH.

Processes such as protein inhibition or induction are known to betime-dependent, and so interaction effects based on said processes arealso likewise time-dependent. In specific cases, these dynamic effects,which take place on a time scale of several days or weeks, can requirethe need for adaptation of the dose of a medicament over the course oftherapy. A simple static consideration or merely the issuing of awarning to the handler in the case of immediate administration ofmutually influencing medicaments, as are known according to the priorart, does not do justice to such complex, dynamic effects.

Exemplarily, the method according to the invention is capable ofsimulating the steady-state plasma levels of the four substancestamoxifen, 4-hydroxytamoxifen, N-desmethyltamoxifen and endoxifen inbreast cancer patients with differing CYP2D6 genotypes or phenotypesaccording to the tamoxifen dose. Through an adaptation of the tamoxifendose, which may be necessary, and a simultaneous simulation ofadministration of increasing endoxifen dosages, the model makes itpossible to address the question of the optimal dosage of the two activeingredients in CYP2D6 IMs and PMs. In this specific case, thesteady-state plasma levels are the pharmacologically critical parameter;the precise time course of the plasma concentration is secondary here.According to the invention, a suitable combination of substances isusually determined per genotype or phenotype, which combinationcompensates for the difference of said genotype or phenotype compared tothe reference.

As dosage form, commercially available 20 mg tamoxifen tabletformulations with a once daily administration were taken as a basis,with none of the formulations being delayed or retarded on account ofthe formulation. Such a dosage form is, for example, described in theproduct information for Nolvadex® 20 mg film-coated tablets from AstraZeneca or for Tamoxifen-Ratiopharm® 10 mg/20 mg/30 mg tablets fromRatiopharm, in section 6.1 in both cases.

In the present example, it was possible to show that a combinationconsisting of 20 mg of tamoxifen and 3 mg of endoxifen in CYP2D6 PMsleads to plasma levels of tamoxifen, N-desmethyltamoxifen,4-hydroxytamoxifen and endoxifen that are comparable to those in thecase of sole administration of 20 mg of tamoxifen in CYP2D6 EMs. InCYP2D6 IMs, the combination of 20 mg of tamoxifen and 1 mg of endoxifenwas found to be optimal (FIGS. 5-7).

The present invention therefore further provides:

-   -   a fixed-dose combination formulation comprising 15-25 mg of        tamoxifen and 0.25-5.0 mg of endoxifen.    -   More particularly:    -   a fixed-dose combination formulation for CYP2D6 IM patients        comprising 15-25 mg of tamoxifen and 0.25-2.00 mg of endoxifen,        more particularly 18-22 mg of tamoxifen and 0.5-1.5 mg of        endoxifen, particularly preferably 20 mg of tamoxifen and 1.0 mg        of endoxifen (FIG. 8 A b)) and    -   a fixed-dose combination formulation for CYP2D6 PM patients        comprising 15-25 mg of tamoxifen and 1.0-5.0 mg of endoxifen,        more particularly 18-22 mg of tamoxifen and 2.0-4.0 mg of        endoxifen, more particularly 20 mg of tamoxifen and 3.0 mg of        endoxifen (FIG. 8 A c)).

Further components of the formulation according to the invention areknown from the above mentioned prior art. For the preparation of aformulation according to the invention, use is made of the formulationfrom, inter alia, the product information for Nolvadex® 20 mgfilm-coated tablets from Astra Zeneca or for Tamoxifen-Rationpharm® 10mg/20 mg/30 mg tablets from Ratiopharm and Ahmad, A., et al., Endoxifen,a new cornerstone of breast cancer therapy: demonstration of safety,tolerability, and systemic bioavailability in healthy human subjects.Clin Pharmacol Ther, 2010. 88(6): p. 814-7 bzw. US 2009-0291134 A1.

In order to achieve higher endoxifen exposures in breast cancerpatients, the tamoxifen dose was, in the past, also increased on anexperimental basis. Instead of the 20 mg of tamoxifen per day, which iseffective in CYP2D6 EM, up to 40 mg of tamoxifen per day as twoindividual doses were administered in CYP2D6 IMs and PMs. However, eventhis severe increase in the dose of the parent substance did not lead tothe endoxifen concentrations observed in CYP2D6 EMs following atherapeutic dose of 20 mg of tamoxifen [Irvin, W. J., Jr., et al.,Genotype-Guided Tamoxifen Dosing Increases Active Metabolite Exposure inWomen With Reduced CYP2D6 Metabolism: A Multicenter Study. J Clin Oncol,2011. 29(24): p. 3232-9.]. Therefore, a particular advantage of thedescribed genotype- or phenotype-specific combined administration oftamoxifen and endoxifen is that the tamoxifen exposure in CYP2D6 IMs andPMs is not greatly elevated compared to the CP2D6 EMs (in contrast tothe increase in tamoxifen dose that is currently being propagated in thescientific community).

However, since tamoxifen (and similarly the propagated non-fixed-dosecombination therapy of tamoxifen and endoxifen in CYP2D6 PMs and IMs)must be taken once daily over a long period (typically 5 years), asecond difficulty of a potential combination therapy is that of ensuringbest possible compliance. It is known that compliance (and thus thesuccess of treatment) in the case of a medicamentous therapy drops withthe number of tablets which must be taken. For this reason, it isadvantageous to combine tamoxifen and endoxifen to form an FDC. An FDCthen contains in each case a defined dose of the two active ingredients,dependent on the CYP2D6 genotype or phenotype (PM or IM), in the form ofa single dosage form (e.g. tablet or capsule).

Thus, a further preferred embodiment of the invention is in each case agenotype- or phenotype-specific fixed-dose combination of tamoxifen andendoxifen in the aforementioned ratios.

The approach shown using the example of tamoxifen/endoxifen can also bereadily transferred to other combinations of parent substance plus one(or more) metabolites, the formation of which is influenced by genotypicor phenotypic particularities and by the phenomenon of “phenotypecopying”, which has already been mentioned above. More particularly, forthe optimization of codeine action, an 1-DC, more precisely a genotype-or phenotype-specific FDC of codeine and morphine (the conversion ofwhich from codeine is likewise catalysed by CYP2D6), would beapplicable.

Examples of further potential candidates would be, inter alia:ezlopitant, donepezil, clopidogrel, cyclophosphamide, azathioprine,irinotecan, leflunomide, capecitabine, prasugrel, venlafaxine, losartan,tolterodine, tramadol, oxycodone, hydrocodone, doxorubicin,mycophenolate mofetil, estramustine, ifosfamide, gemcitabine, etoposide,terfenadine, methotrexate.

The described invention of a pharmaceutical formulation, preferably anFDC, containing a parent substance and one or more metabolites can bereadily transferred to other active-ingredient candidates. In thetamoxifen-endoxifen example detailed above, the problem is theinsufficient conversion of tamoxifen to endoxifen in patients having aCYP2D6 IM or PM phenotype. As shown exemplarily, the combination of thestandard dose of the parent substance with a genotype- orphenotype-specific endoxifen dose for CYP2D6 IMs or for CYP2D6 PMs in afixed combined pharmaceutical formulation can make up for thisinsufficiency and differences in the therapy response are eliminated.

Essentially, the principle of a genotype- or phenotype-specificpharmaceutical formulation, preferably an 1-DC, consisting of a parentsubstance and one or more metabolites can be firstly transferred to allparent substances which, owing to a polymorphic enzyme, protein,receptor or transporter, are converted into one or more activemetabolites and/or bound and/or transported and/or develop theirpharmacodynamic action.

A further example of the conversion of a parent substance into an activemetabolite via a polymorphic enzyme is clopidogrel. Clopidogrel inhibitsblood coagulation, after it has been converted into its activemetabolite, by blocking ADP-dependent thrombocyte activation via theglycoprotein IIb/IIIa receptor complex. Clopidogrel is converted intoits active metabolite via, inter alia, the polymorphic enzyme CYP2C19.CYP2C19 is subject to a pronounced genetic polymorphism. Similar toCYP2D6, CYP2C19 PMs can therefore be found in the population. Here, too,it is reasonable to suspect that patients having a CYP2C19 P M genotypeor phenotype might not benefit sufficiently from therapy withclopidogrel [Simon T, Bhatt D L, Bergougnan L, Farenc C, Pearson K,Perrin L, Vicaut E, Lacreta F, Hurbin F, Dubar M.; Genetic polymorphismsand the impact of a higher clopidogrel dose regimen on active metaboliteexposure and antiplatelet response in healthy subjects., Clin PharmacolTher. 2011 August; 90(2):287-95.; Lee J B, Lee K A, Lee K Y.; CytochromeP450 2C19 polymorphism is associated with reduced clopidogrel responsein cerebrovascular disease. Yonsei Med J. 2011 September; 52(5):734-8.;Kazui M, Nishiya Y, Ishizuka T, Hagihara K, Farid N A, Okazaki O, IkedaT, Kurihara A.; Identification of the human cytochrome P450 enzymesinvolved in the two oxidative steps in the bioactivation of clopidogrelto its pharmacologically active metabolite. Drug Metab Dispos. 2010January; 38(1):92-9.; Savi P, Pereillo J M, Uzabiaga M F, Combalbert J,Picard C, Maffrand J P, Pascal M, Herbert J M.; Identification andbiological activity of the active metabolite of clopidogrel. ThrombHaemost. 2000 November, 84(5):891-6.; Cervinski M A, Schwab M C,Lefferts J A, Lewis L D, Lebel K A, Tyropolis A M, Pflueger S M,Tsongalis G J.; Establishment of a CYP2C19 genotyping assay for clinicaluse. Am J Clin Pathol. 2013 February, 139(2):202-7; Frelinger A L 3rd,Lee R D, Mulford D J, Wu J, Nudurupati S, Nigam A, Brooks J K, Bhatt DL, Michelson A D.; A randomized, 2-period, crossover design study toassess the effects of dexlansoprazole, lansoprazole, esomeprazole, andomeprazole on the steady-state pharmacokinetics and pharmacodynamics ofclopidogrel in healthy volunteers. J Am Coll Cardiol. 2012 Apr. 3,59(14):1304-11.; Gong I Y, Crown N, Suen C M, Schwarz U I, Dresser G K,Knauer M J, Sugiyama D, Degorter M K, Woolsey S, Tirona R G, Kim R B.;Clarifying the importance of CYP2C19 and PON1 in the mechanism ofclopidogrel bioactivation and in vivo antiplatelet response. Eur HeartJ. 2012 November, 33(22):2856-2464a.; Mega J L, Hochholzer W, FrelingerA L 3rd, Kluk M J, Angiolillo D J, Kereiakes D J, Isserman S, Rogers WJ, Ruff C T, Contant C, Pencina M J, Scirica B M, Longtine J A,Michelson A D, Sabatine M S.; Dosing clopidogrel based on CYP2C19genotype and the effect on platelet reactivity in patients with stablecardiovascular disease. JAMA. 2011 Nov. 23, 306(20):2221-8.; Zabalza M,Subirana I, Sala J, Lluis-Ganella C, Lucas G, Tomas M, Masia R, MarrugatJ, Brugada R, Elosua R.; Meta-analyses of the association betweencytochrome CYP2C19 loss- and gain-of-function polymorphisms andcardiovascular outcomes in patients with coronary artery disease treatedwith clopidogrel. Heart. 2012 January; 98(2):100-8., Yamamoto K,Hokimoto S, Chitose T, Morita K, Ono T, Kaikita K, Tsujita K, Abe T,Deguchi M, Miyagawa H, Saruwatari J, Sumida H, Sugiyama S, Nakagawa K,Ogawa H., Impact of CYP2C19 polymorphism on residual platelet reactivityin patients with coronary heart disease during antiplatelet therapy. JCardiol. 2011 March; 57(2):194-201.; Jin B, Ni H C, Shen W, Li J, Shi HM, Li Y.; Cytochrome P450 2C19 polymorphism is associated with poorclinical outcomes in coronary artery disease patients treated withclopidogrel. Mol Biol Rep. 2011 March; 38(3):1697-702., Shuldiner A R,O'Connell J R, Bliden K P, Gandhi A, Ryan K, Horenstein R B, Damcott CM, Pakyz R, Tantry U S, Gibson Q, Pollin T I, Post W, Parsa A, MitchellB D, Faraday N, Herzog W, Gurbel P A.; Association of cytochrome P4502C19 genotype with the antiplatelet effect and clinical efficacy ofclopidogrel therapy. JAMA. 2009 Aug. 26, 302(8):849-57.; Sibbing D,Stegherr J, Latz W, Koch W, Mehilli J, Donler K, Morath T, Schomig A,Kastrati A, von Beckerath N.; Cytochrome P450 2C19 loss-of-functionpolymorphism and stent thrombosis following percutaneous coronaryintervention. Eur Heart J. 2009 April, 30(8):916-22.; Hulot J S, Bura A,Villard E, Azizi M, Remones V, Goyenvalle C, Aiach M, Lechat P, GaussemP.; Cytochrome P450 2C19 loss-of-function polymorphism is a majordeterminant of clopidogrel responsiveness in healthy subjects. Blood.2006 Oct. 1, 108(7):2244-71. Using the concept according to theinvention, it is possible too in this case to calculate a genotype- orphenotype-specific pharmaceutical formulation, preferably an FDC,consisting of clopidogrel and its active metabolite in order to make upfor the insufficient formation of active metabolite in CYP2C19 PMs.

To determine the optimal reference steady-state plasma level, it ispossible to use either determined data, or a pharmacokinetic model suchas PK-Sim® and MoBi® which can calculate the plasma level after input ofa reference dose.

Furthermore, the principle of a genotype- or phenotype-specificpharmaceutical formulation, preferably an FDC, consisting of a parentsubstance and one or more metabolites can be transferred to all parentsubstances which, by means of an enzyme, protein, receptor ortransporter which can be inhibited/induced, are converted into one ormore active metabolites and/or bound and/or transported and/or developtheir pharmacodynamic action.

As already detailed above using the example of tamoxifen and the CYP2D6inhibitor paroxetine, the required simultaneous administration of apharmaceutical ingredient A and a pharmaceutical ingredient B, where Amust be converted into an active metabolite via an enzyme in order todevelop its entire action and B inhibits said enzyme, can in effectconvert a patient from an EM genotype or phenotype into a PM genotype orphenotype. As a result of the medically indicated simultaneousadministration of paroxetine, the patient is in effect converted into aCYP2D6 PM, which can, accordingly, convert less tamoxifen intoendoxifen. Using the concept detailed above, it is likewise possiblehere to calculate a genotype- or phenotype-specific pharmaceuticalformulation, preferably an FDC, consisting of tamoxifen and endoxifenwhich can make up for the insufficiency of endoxifen formation fromtamoxifen owing to the inhibition of CYP2D6 caused by paroxetine.

Analogously, the concept according to the invention is applicable in thecase of a required and medically indicated simultaneous administrationof clopidogrel and the competitive CYP2C19 inhibitor omeprazole. Aresulting reduced conversion of clopidogrel into its active metabolitecan likewise be made up for, using the concept and method detailedabove, by calculating a genotype- or phenotype-specific pharmaceuticalformulation, preferably an FDC, consisting of clopidogrel and its activemetabolite.

The concept explained above is also capable of compensating for acombination of a genetic polymorphism and an enzyme inhibition and/orenzyme induction which additively reduce/increase the same or differentenzymes or proteins or receptors or transporters in terms of theiractivity. This is explained exemplarily using the example of a patienthaving a CYP2D6 PM genotype or phenotype who is receiving tamoxifentherapy and additionally requires the administration of paroxetine. Theeffect on the formation of endoxifen from tamoxifen via CYP2D6 can betaken into account by the principle detailed above and an optimalgenotype- or phenotype-specific pharmaceutical formulation, preferablyan FDC, consisting of tamoxifen and endoxifen can be calculated.Analogously, this can also be comprehended using the example of apatient having a CYP2C19 PM genotype or phenotype under clopidogreltherapy who now requires the administration of omeprazole.

FIGURES

The figures illustrate the inventive concept for tamoxifen therapy andshow the results of the tamoxifen/endoxifen FDC dose finding usingPK-Sim® as per the method according to the invention as an example,without restricting the concept to said example.

FIG. 1 shows an extract from the complex biotransformation scheme fortamoxifen in humans. About 90% of tamoxifen is metabolized toN-desmethyltamoxifen and about 7% to 4-hydroxytamoxifen. Endoxifen isformed from N-desmethyltamoxifen exclusively via the polymorphiccytochrome P450 (CYP) 2D6. The formation of 4-hydroxytamoxifen fromtamoxifen occurs via the polymorphic CYP2D6 to an extent of about 50%.Thus, CYP2D6 is largely involved in the essential endoxifen formationsteps [Coller, J. K., N. Krebsfaenger, et al. (2002). “The influence ofCYP2B6, CYP2C9 and CYP2D6 genotypes on the formation of the potentantioestrogen Z-4-hydroxy-tamoxifen in human liver.” Br J Clin Pharmacol54(2): 157-167.; Desta, Z., B. A. Ward, et al. (2004). “Comprehensiveevaluation of tamoxifen sequential biotransformation by the humancytochrome P450 system in vitro: prominent roles for CYP3A and CYP2D6.”J Pharmacol Exp Ther 310(3): 1062-1075.; Kaku, T., K. Ogura, et al.(2004). “Quaternary ammonium-linked glucuronidation of tamoxifen byhuman liver microsomes and UDP-glucuronosyltransferase 1A4.” BiochemPharmacol 67(11): 2093-2102.; Murdter. T. E., W. Schroth, et al. (2011).“Activity levels of tamoxifen metabolites at the estrogen receptor andthe impact of genetic polymorphisms of phase I and II enzymes on theirconcentration levels in plasma.” Clin Pharmacol Ther 89(5): 708-717.;Nishiyama, T., K. Ogura. et al. (2002). “Reverse geometrical selectivityin glucuronidation and sulfation of cis- and trans-4-hydroxytamoxifensby human liver UDP-glucuronosyltransferases and sulfotransferases.”Biochem Pharmacol 63(10): 1817-1830.; Sun, D., G. Chen, et al. (2006).“Characterization of tamoxifen and 4-hydroxytamoxifen glucuronidation byhuman UGT1A4 variants.” Breast Cancer Res 8(4): R50.; Sun, D., A. K.Sharma, et al. (2007). “Glucuronidation of active tamoxifen metabolitesby the human UDP glucuronosyltransferases.” Drug Metab Dispos 35(11):2006-2014.]

FIGS. 2A through 2C show cytochrome P450 (CYP) 2D6 genotype- orphenotype-dependent steady-state concentrations of endoxifen in thecontext of tamoxifen therapy in patients of the CYP2D6 extensivemetabolizer (EM), intermediate metabolizer (IM) or poor metabolizer (PM)phenotype. A gene dosage effect of the endoxifen concentration isevident: patients having two functional CYP2D6 alleles (EMs) show adistinctly higher endoxifen exposure than patients having only oneCYP2D6 functional allele (IMs) or no functional CYP2D6 allele (PM). FIG.2A: Kiyotani, K., T. Mushiroda, et al. (2010). “Significant effect ofpolymorphisms in CYP2D6 and ABCC2 on clinical outcomes of adjuvanttamoxifen therapy for breast cancer patients.” J Clin Oncol 28(8):1287-1293.; Murdter, T. E., W. Schroth, et al. (2011). “Activity levelsof tamoxifen metabolites at the estrogen receptor and the impact ofgenetic polymorphisms of phase I and II enzymes on their concentrationlevels in plasma.” Clin Pharmacol Ther 89(5): 708-717.; FIG. 2B: Lim, J.S., X. A. Chen, et al. (2011). “Impact of CYP2D6, CYP3A5, CYP2C9 andCYP2C19 polymorphisms on tamoxifen pharmacokinetics in Asian breastcancer patients.” Br J Clin Pharmacol 71(5): 737-750.; Lim, H. S., H. JuLee, et al. (2007). “Clinical implications of CYP2D6 genotypespredictive of tamoxifen pharmacokinetics in metastatic breast cancer.” JClin Oncol 25(25): 3837-3845.; FIG. 2C: Borges, S., Z. Desta, et al.(2006). “Quantitative effect of CYP2D6 genotype and inhibitors ontamoxifen metabolism: implication for optimization of breast cancertreatment.” Clin Pharmacol Ther 80(1): 61-74.; Jin, Y., Z. Desta, et al.(2005). “CYP2D6 Genotype, Antidepressant Use, and Tamoxifen MetabolismDuring Adjuvant Breast Cancer Treatment.” Journal of the National CancerInstitute 97(1): 30-39.]

FIGS. 3A and 3B show relapse-free survival curves (Kaplan-Meier) forbreast cancer patients under tamoxifen therapy according to thecytochrome P450 (CYP) 2D6 extensive metabolizer (EM), intermediatemetabolizer (IM). or poor metabolizer (PM) genotype or phenotype. FIG.3A: Time to (breast cancer) recurrence (left) and event-freesurvival/relapse-free survival (right). FIG. 3B: Disease-free survival(left) and overall survival (right). [Figures from (group 1 to 3):Schroth, W., M. P. Goetz, et al. (2009). “Association between CYP2D6polymorphisms and outcomes among women with early stage breast cancertreated with tamoxifen.” JAMA 302(13): 1429-1436.; Goetz, M. P., S. K.Knox, et al. (2007). “The impact of cytochrome P450 2D6 metabolism inwomen receiving adjuvant tamoxifen.” Breast Cancer Res Treat 101(1):113-121.; Goetz, M. P., J. M. Rae, et al. (2005). “Pharmacogenetics oftamoxifen biotransformation is associated with clinical outcomes ofefficacy and hot flashes.” J Clin Oncol 23(36): 9312-9318.]

FIGS. 4A and 4B show a diagram of the compartments of the coupledphysiologically based pharmacokinetic (PBPK) model as used in PK-Sim®for the simulation of the cytochrome P450 (CYP) 2D6 genotype- orphenotype-specific formation of N-desmethyltamoxifen, 4-hydroxytamoxifenand endoxifen following the administration of the parent substancetamoxifen or for the simulation of the simultaneous administration oftamoxifen and endoxifen according to the CYP2D6 genotype or phenotypeand the resulting serum concentrations. In the intracellular compartmentof the liver, tamoxifen gives rise to N-desmethyltamoxifen and4-hydroxytamoxifen, and so the tamoxifen PBPK model acts as a developingfunction for the two primary metabolites. Analogously, the secondarymetabolite endoxifen arises in the intracellular compartments of thePBPK models of N-desmethyltamoxifen and 4-hydroxytamoxifen.

FIG. 5A shows coupled PBPK models for tamoxifen (TAM),N-desmethyltamoxifen (NDM), 4-hydroxytamoxifen (4OH), endoxifen (END) inCYP2D6 extensive metabolizer, intermediate metabolizer and poormetabolizer (EM/IM/PM) genotype or phenotype populations. Steady-stateplasma concentrations of tamoxifen, N-desmethyltamoxifen,4-hydroxytamoxifen and endoxifen following once daily administration of20 mg of tamoxifen over 1 year in example populations of European womenof the cytochrome P450 (CYP) 2D6 extensive metabolizer (EM),intermediate metabolizer (IM) and poor metabolizer (PM) genotype orphenotype. Box-and-whisker plots show the 5th, 25th, 50th, 75th, and95th percentiles of the respective populations. Symbols representexperimental data for the model validation [from left to right: Gjerde,J. Geisler, et al. (2010). “Associations between tamoxifen, estrogens,and FSH serum levels during steady state tamoxifen treatment ofpostmenopausal women with breast cancer.” BMC Cancer 10: 313.; Gjerde,J., M. Hauglid, et al. (2008). “Effects of CYP2D6 and SULT1A1 genotypesincluding SULT1A1 gene copy number on tamoxifen metabolism.” Ann Oncol19(1): 56-61.; Madlensky, L., L. Natarajan, et al. (2011). “Tamoxifenmetabolite concentrations, CYP2D6 genotype, and breast cancer outcomes.”Clin Pharmacol Ther 89(5): 718-725.; Murdter, T. E., W. Schroth, et al.(2011). “Activity levels of tamoxifen metabolites at the estrogenreceptor and the impact of genetic polymorphisms of phase I and IIenzymes on their concentration levels in plasma.” Clin Pharmacol Ther89(5): 708-717.; Irvin, W. J., Jr., C. M. Walko, et al. (2011).“Genotype-Guided Tamoxifen Dosing Increases Active Metabolite Exposurein Women With Reduced CYP2D6 Metabolism: A Multicenter Study.” J ClinOncol 29(24): 3232-3239.]. FIG. 5B shows an alternative depiction.

FIG. 6A shows the result of the endoxifen dose finding using PK-Sim® asper the method according to the invention for the simultaneousadministration with tamoxifen in CYP2D6 IM patients. FIG. 6A showssteady-state plasma concentrations of tamoxifen (TAM),N-desmethyltamoxifen (NDM). 4-hydroxytamoxifen (4OH) and endoxifen (END)following once daily administration of 20 mg of tamoxifen on a dailybasis over 1 year in example populations of European patients with thecytochrome P450 (CYP) 2D6 extensive metabolizer (EM) or intermediatemetabolizer (IM) genotype or phenotype in comparison with experimentaldata from patients of the CYP2D6 EM genotype or phenotype. Steady-stateplasma concentrations of tamoxifen, N-desmethyltamoxifen,4-hydroxytamoxifen and endoxifen in example populations of Europeanpatients of the CYP2D6 IM genotype or phenotype following simultaneousonce daily administration of 20 mg of tamoxifen plus 0.5 mg or 1 mg or1.5 mg of endoxifen, in addition, over 1 year. CYP2D6 IM patients whoreceived 20 mg of tamoxifen plus 1 mg of endoxifen showed equivalentendoxifen concentrations with respect to CYP2D6 EM patients who received20 mg of tamoxifen once daily over 1 year. [From left to right: Gjerde,J. Geisler, et al. (2010). “Associations between tamoxifen, estrogens,and FSH serum levels during steady state tamoxifen treatment ofpostmenopausal women with breast cancer.” BMC Cancer 10: 313.; Gjerde,J., M. Hauglid, et al. (2008). “Effects of CYP2D6 and SULT1A1 genotypesincluding SULT1A1 gene copy number on tamoxifen metabolism.” Ann Oncol19(1): 56-61.; Madlensky, L., L. Natarajan, et al. (2011). “Tamoxifenmetabolite concentrations, CYP2D6 genotype, and breast cancer outcomes.”Clin Pharmacol Ther 89(5): 718-725.; Murdter, T. E., W. Schroth, et al.(2011). “Activity levels of tamoxifen metabolites at the estrogenreceptor and the impact of genetic polymorphisms of phase I and IIenzymes on their concentration levels in plasma.” Clin Pharmacol Ther89(5): 708-717.; Irvin. W. J., Jr., C. M. Walko, et al. (2011).“Genotype-Guided Tamoxifen Dosing Increases Active Metabolite Exposurein Women With Reduced CYP2D6 Metabolism: A Multicenter Study.” J ClinOncol 29(24): 3232-3239] FIG. 6B shows an alternative depiction. Servingas comparison are the determined steady-state trough plasmaconcentrations of tamoxifen (TAM), N-desmethyltamoxifen (NDM),4-hydroxytamoxifen (4OH) and endoxifen (END) in European patients of theCYP2D6 EM genotype or phenotype following once daily administration of20 mg of tamoxifen over 1 year, shown as a grey band (5th-95thpercentiles) with a median (dark-grey line). CYP2D6 IM patients whoreceived 20 mg of tamoxifen plus 1 mg of endoxifen showed equivalentendoxifen concentrations with respect to CYP2D6 EM patients who received20 mg of tamoxifen once daily over 1 year.

FIG. 7A shows the result of the endoxifen dose finding using PK-Sim® asper the method according to the invention for the simultaneous oncedaily administration with tamoxifen in CYP2D6 PM patients. FIG. 7A showssteady-state plasma concentrations of tamoxifen (TAM),N-desmethyltamoxifen (NDM), 4-hydroxytamoxifen (4OH) and endoxifen (END)following administration of 20 mg of tamoxifen once daily over 1 year inexample populations of European patients with the cytochrome P450 (CYP)2D6 extensive metabolizer (EM) or poor metabolizer (PM) genotype orphenotype in comparison with experimental data from patients of theCYP2D6 EM genotype or phenotype. Steady-state plasma concentrations oftamoxifen, N-desmethyltamoxifen, 4-hydroxytamoxifen and endoxifen inexample populations of European patients of the CYP2D6 PM genotype orphenotype following simultaneous administration of 20 mg of tamoxifenplus 1 mg or 2 mg or 3 mg or 4 mg of endoxifen, in addition, over 1year. CYP2D6 PM patients who received 20 mg of tamoxifen plus 3 mg ofendoxifen showed equivalent endoxifen concentrations with respect toCYP2D6 EM patients who received 20 mg of tamoxifen once daily over 1year. [From left to right: Gjerde, J. Geisler, et al. (2010).“Associations between tamoxifen, estrogens, and FSH serum levels duringsteady state tamoxifen treatment of postmenopausal women with breastcancer.” BMC Cancer 10: 313.; Gjerde, J., M. Hauglid, et al. (2008).“Effects of CYP2D6 and SULT1A1 genotypes including SULT1A1 gene copynumber on tamoxifen metabolism.” Ann Oncol 19(1): 56-61.; Madlensky, L.,L. Natarajan, et al. (2011). “Tamoxifen metabolite concentrations,CYP2D6 genotype, and breast cancer outcomes.” Clin Pharmacol Ther 89(5):718-725.; Murdter, T. E., W. Schroth, et al. (2011). “Activity levels oftamoxifen metabolites at the estrogen receptor and the impact of geneticpolymorphisms of phase I and II enzymes on their concentration levels inplasma.” Clin Pharmacol Ther 89(5): 708-717.; Irvin, W. J., Jr., C. M.Walko, et al. (2011). “Genotype-Guided Tamoxifen Dosing Increases ActiveMetabolite Exposure in Women With Reduced CYP2D6 Metabolism: AMulticenter Study.” J Clin Oncol 29(24): 3232-3239.1 FIG. 7B shows analternative depiction. Serving as comparison are the pre-determinedsteady-state trough plasma concentrations of tamoxifen (TAM),N-desmethyltamoxifen (NDM), 4-hydroxytamoxifen (4OH) and endoxifen (END)in European patients of the CYP2D6 EM genotype or phenotype followingonce daily administration of 20 mg of tamoxifen over 1 year, shown as agrey band (5th-95th percentiles) with a median (dark-grey line). CYP2D6PM patients who received 20 mg of tamoxifen plus 3 mg of endoxifenshowed equivalent endoxifen concentrations with respect to CYP2D6 EMpatients who received 20 mg of tamoxifen once daily over 1 year.

FIG. 8 shows genotype- or phenotype-based dosing of tamoxifen andendoxifen as a loose combination (A) or as an FDC (B).

FIGS. 9 and 10 show a diagram of the modular design of PK-Sim®.

FIGS. 11 to 14 show the influence of an initial breast cancer therapywith the fixed combination of 20 mg of tamoxifen and 3 mg of endoxifenon the attainment of the endoxifen steady-state concentrations,systematically investigated by means of the PBPK model for CYP2D6 EMsand IMs.

FIG. 11 shows the result of the loading dose study using PK-Sim® as perthe method according to the invention for the simultaneousadministration of tamoxifen and endoxifen in CYP2D6 EM patients. FIG. 11shows the trough plasma concentrations of tamoxifen (TAM),N-desmethyltamoxifen (NDM), 4-hydroxytamoxifen (4OH) and endoxifen (END)following simultaneous once daily administration of 20 mg of tamoxifenand 3 mg of endoxifen in European patients having the cytochrome P450(CYP) 2D6 extensive metabolizer (EM) genotype or phenotype. Serving ascomparison are the pre-determined steady-state trough plasmaconcentrations of tamoxifen (TAM), N-desmethyltamoxifen (NDM),4-hydroxytamoxifen (4OH) and endoxifen (END) in European patients of theCYP2D6 EM genotype or phenotype following once daily administration of20 mg of tamoxifen over 1 year, shown as a grey band (5th-95thpercentiles) with a median (dark-grey line). Taken as the time point wasthe day before the day on which the median trough level of the endoxifenconcentration first exceeds the median trough-level endoxifenconcentration in the example population consisting of European patientsof the CYP2D6 EM genotype or phenotype under standard therapy, in thiscase, day 9.

FIG. 12 shows the result of the loading-dose control study using PK-Sim®as per the method according to the invention for the simultaneousadministration of tamoxifen and endoxifen in CYP2D6 EM patients. FIG. 12shows the trough plasma concentrations of tamoxifen (TAM),N-desmethyltamoxifen (NDM), 4-hydroxytamoxifen (4OH) and endoxifen (END)following simultaneous once daily administration of 20 mg of tamoxifenin European patients having the cytochrome P450 (CYP) 2D6 extensivemetabolizer (EM) genotype or phenotype. Serving as comparison are thepre-determined steady-state trough plasma concentrations of tamoxifen(TAM), N-desmethyltamoxifen (NDM), 4-hydroxytamoxifen (4OH) andendoxifen (END) in European patients of the CYP2D6 EM genotype orphenotype following once daily administration of 20 mg of tamoxifen over1 year, shown as a grey band (5th-95th percentiles) with a median(dark-grey line). Taken as the time point was the day on which themedian trough level of the endoxifen concentration first reaches themedian trough-level endoxifen concentration in the example populationconsisting of European patients of the CYP2D6 EM genotype or phenotypeunder standard therapy, in this case, day 120.

FIG. 13 shows the result of the loading dose study using PK-Sim® as perthe method according to the invention for the simultaneousadministration of tamoxifen and endoxifen in CYP2D6 IM patients. FIG. 13shows the trough plasma concentrations of tamoxifen (TAM),N-desmethyltamoxifen (NDM), 4-hydroxytamoxifen (4OH) and endoxifen (END)following simultaneous once daily administration of 20 mg of tamoxifenand 3 mg of endoxifen in European patients having the cytochrome P450(CYP) 2D6 intermediate metabolizer (IM) genotype or phenotype. Servingas comparison are the pre-determined steady-state trough plasmaconcentrations of tamoxifen (TAM), N-desmethyltamoxifen (NDM),4-hydroxytamoxifen (4OH) and endoxifen (END) in European patients of theCYP2D6 EM genotype or phenotype following once daily administration of20 mg of tamoxifen over 1 year, shown as a grey band (5th-95thpercentiles) with a median (dark-grey line). Taken as the time point wasthe day before the day on which the median trough level of the endoxifenconcentration first exceeds the median trough-level endoxifenconcentration in the example population consisting of European patientsof the CYP2D6 EM genotype or phenotype under standard therapy, in thiscase, day 13.

FIG. 14 shows the result of the loading-dose control study using PK-Sim®as per the method according to the invention for the simultaneousadministration of tamoxifen and endoxifen in CYP2D6 IM patients. FIG. 14shows the trough plasma concentrations of tamoxifen (TAM),N-desmethyltamoxifen (NDM), 4-hydroxytamoxifen (4OH) and endoxifen (END)following simultaneous once daily administration of 20 mg of tamoxifenand 1 mg of endoxifen in European patients having the cytochrome P450(CYP) 2D6 intermediate metabolizer (IM) genotype or phenotype. Servingas comparison are the pre-determined steady-state trough plasmaconcentrations of tamoxifen (TAM), N-desmethyltamoxifen (NDM),4-hydroxytamoxifen (4OH) and endoxifen (END) in European patients of theCYP2D6 EM genotype or phenotype following once daily administration of20 mg of tamoxifen over 1 year, shown as a grey band (5th-95thpercentiles) with a median (dark-grey line). Taken as the time point wasthe day on which the median trough level of the endoxifen concentrationfirst reaches the median trough-level endoxifen concentration in theexample population consisting of European patients of the CYP2D6 EMgenotype or phenotype under standard therapy, in this case, day 67.

In summary, the direct comparison between the administration of 20 mg oftamoxifen in CYP2D6 EMs or 20 mg of tamoxifen and 1 mg of endoxifenaccording to the invention in IMs and the administration according tothe invention of 20 mg of tamoxifen and 3 mg of endoxifen in CYP2D6 EMsor IMs clearly shows that the endoxifen steady-state concentration isreached substantially faster with the administration of the FDC(consisting of 20 mg of tamoxifen and 3 mg of endoxifen), on averageabout 111 days or 54 days faster, than with the standard dose(consisting of 20 mg of tamoxifen for EMs and 20 mg of tamoxifen and 1mg of endoxifen according to the invention).

FIGS. 15 to 18 show simulations in the investigation of non-compliance.The following scenarios were simulated:

FIG. 15 shows the result of the compliance-dose study using PK-Sim® asper the method according to the invention for the simultaneousadministration of tamoxifen and endoxifen in CYP2D6 EM patients. FIG. 15shows the trough plasma concentrations of tamoxifen (TAM),N-desmethyltamoxifen (NDM). 4-hydroxytamoxifen (4OH) and endoxifen (END)following administration of 20 mg of tamoxifen once daily for 6 monthsand drug holidays of 2, 4, 8 and 12 weeks in duration in Europeanpatients having the cytochrome P450 (CYP) 2D6 extensive metabolizer (EM)genotype or phenotype. This was subsequently followed by thesimultaneous once daily administration of 20 mg of tamoxifen and 3 mg ofendoxifen. Serving as comparison are the pre-determined steady-statetrough plasma concentrations of tamoxifen (TAM), N-desmethyltamoxifen(NDM), 4-hydroxytamoxifen (4OH) and endoxifen (END) in European patientsof the CYP2D6 EM genotype or phenotype following once dailyadministration of 20 mg of tamoxifen over 1 year, shown as a grey band(5th-95th percentiles) with a median (dark-grey line). Taken as the timepoint was the day before the day on which the median trough level of theendoxifen concentration first exceeds the median trough-level endoxifenconcentration in the example population consisting of European patientsof the CYP2D6 EM genotype or phenotype under standard therapy, in thiscase, day 2 after the start of FDC intake in the case of the 2-week drugholiday, day 3 after the start of FDC intake in the case of the 4-weekdrug holiday, day 7 after the start of FDC intake in the case of the8-week drug holiday, and day 9 after the start of FDC intake in the caseof the 12-week drug holiday.

FIG. 16 shows the result of the compliance-dose control study usingPK-Sim® as per the method according to the invention for thesimultaneous administration of tamoxifen and endoxifen in CYP2D6 EMpatients. FIG. 16 shows the trough plasma concentrations of tamoxifen(TAM), N-desmethyltamoxifen (NDM), 4-hydroxytamoxifen (4OH) andendoxifen (END) following administration of 20 mg of tamoxifen oncedaily for 6 months and drug holidays of 2, 4, 8 and 12 weeks in durationin European patients having the cytochrome P450 (CYP) 2D6 extensivemetabolizer (EM) genotype or phenotype. This was subsequently followedby the once daily administration of 20 mg of tamoxifen. Serving ascomparison are the pre-determined steady-state trough plasmaconcentrations of tamoxifen (TAM). N-desmethyltamoxifen (NDM),4-hydroxytamoxifen (4OH) and endoxifen (END) in European patients of theCYP2D6 EM genotype or phenotype following once daily administration of20 mg of tamoxifen over 1 year, shown as a grey band (5th-95thpercentiles) with a median (dark-grey line). Taken as the time point wasthe day on which the median trough level of the endoxifen concentrationfirst reaches the median trough-level endoxifen concentration in theexample population consisting of European patients of the CYP2D6 EMgenotype or phenotype under standard therapy, in this case, day 269after the start of FDC intake in the case of the 2-week drug holiday,day 334 after the start of FDC intake in the case of the 4-week drugholiday, day >336 after the start of FDC intake in the case of the8-week drug holiday, and day >336 after the start of FDC intake in thecase of the 12-week drug holiday.

FIG. 17 shows the result of the compliance-dose study using PK-Sim® asper the method according to the invention for the simultaneousadministration of tamoxifen and endoxifen in CYP2D6 IM patients. FIG. 17shows the trough plasma concentrations of tamoxifen (TAM),N-desmethyltamoxifen (NDM), 4-hydroxytamoxifen (4OH) and endoxifen (END)following simultaneous administration of 20 mg of tamoxifen and 1 mg ofendoxifen once daily for 6 months and drug holidays of 2, 4, 8 and 12weeks in duration in European patients having the cytochrome P450 (CYP)2D6 intermediate metabolizer (IM) genotype or phenotype. This wassubsequently followed by the simultaneous once daily administration of20 mg of tamoxifen and 3 mg of endoxifen. Serving as comparison are thepre-determined steady-state trough plasma concentrations of tamoxifen(TAM), N-desmethyltamoxifen (NDM), 4-hydroxytamoxifen (4OH) andendoxifen (END) in European patients of the CYP2D6 EM genotype orphenotype following once daily administration of 20 mg of tamoxifen over1 year, shown as a grey band (5th-95th percentiles) with a median(dark-grey line). Taken as the time point was the day before the day onwhich the median trough level of the endoxifen concentration firstexceeds the median trough-level endoxifen concentration in the examplepopulation consisting of European patients of the CYP2D6 EM genotype orphenotype under standard therapy, in this case, day 4 after the start ofFDC intake in the case of the 2-week drug holiday, day 7 after the startof FDC intake in the case of the 4-week drug holiday, day 10 after thestart of FDC intake in the case of the 8-week drug holiday, and day 11after the start of FDC intake in the case of the 12-week drug holiday.

FIG. 18 shows the result of the compliance-dose control study usingPK-Sim® as per the method according to the invention for thesimultaneous administration of tamoxifen and endoxifen in CYP2D6 IMpatients. FIG. 18 shows the trough plasma concentrations of tamoxifen(TAM), N-desmethyltamoxifen (NDM). 4-hydroxytamoxifen (4OH) andendoxifen (END) following simultaneous administration of 20 mg oftamoxifen and 1 mg of endoxifen once daily for 6 months and drugholidays of 2, 4, 8 and 12 weeks in duration in European patients havingthe cytochrome P450 (CYP) 2D6 intermediate metabolizer (IM) genotype orphenotype. This was subsequently followed by the once daily simultaneousadministration of 20 mg of tamoxifen and 1 mg of endoxifen. Serving ascomparison are the pre-determined steady-state trough plasmaconcentrations of tamoxifen (TAM), N-desmethyltamoxifen (NDM),4-hydroxytamoxifen (4OH) and endoxifen (END) in European patients of theCYP2D6 EM genotype or phenotype following once daily administration of20 mg of tamoxifen over 1 year, shown as a grey band (5th-95thpercentiles) with a median (dark-grey line). Taken as the time point wasthe day on which the median trough level of the endoxifen concentrationfirst reaches the median trough-level endoxifen concentration in theexample population consisting of European patients of the CYP2D6 EMgenotype or phenotype under standard therapy, in this case, day 217after the start of FDC intake in the case of the 2-week drug holiday,day 250 after the start of FDC intake in the case of the 4-week drugholiday, day 283 after the start of FDC intake in the case of the 8-weekdrug holiday, and day 315 after the start of FDC intake in the case ofthe 12-week drug holiday.

In summary, the simulation results from FIGS. 15 to 18 show that thefixed combined administration of 20 mg of tamoxifen and 3 mg ofendoxifen is advantageous for speeding up the attainment of theeffective steady-state concentrations of endoxifen in the event ofnon-compliance.

1. Method for preparing a fixed-dose combination pharmaceuticalformulation, the fixed-dose combination pharmaceutical formulationcomprising a parent substance, the action of which is dependent on thequantity or the activity of expressed protein variants, enzyme variants,receptor variants or transporter variants, and at least one metabolitethereof, and the method comprising the following steps: a) inputtinginto an input module of an organism, of its genotype or phenotype, of aparent substance and at least one metabolite of the parent substance, ofan optimal reference steady-state plasma level for the parent substancefor a reference genotype or reference phenotype in the case of deliveryof the parent substance alone, b) forwarding of the data from a) into acalculation module comprising a substance data module, an organism datamodule, a genotype data module or phenotype data module, and aphysiologically based pharmacokinetic model, wherein the substance datamodule comprises data concerning the physicochemical and/or biochemicalproperties of the substance, the organism module comprises dataconcerning the compartments of the organism, and the genotype datamodule or phenotype data module comprises genotype- orphenotype-specific data, c) automatically selecting parent substance andmetabolite-specific data from the substance data module, d)automatically selecting organism-specific data from the organism datamodule on the basis of input a), e) automatically selectinggenotype-specific or phenotype-specific data from the genotype datamodule or phenotype data module, f) forwarding of the selected data froma) to e) into the physiologically based pharmacokinetic model, g)calculating, by means of the physiologically based pharmacokineticmodel, an optimized dosage for the parent substance for the referencegenotype or reference phenotype in order to attain the inputted optimalreference plasma level for the parent substance from a), h) calculatingthe reference steady-state plasma level for the metabolites for thereference genotype or reference phenotype in the case of administrationof the dose of parent substance calculated in g), i) calculating aplasma level of the metabolites that is reduced owing to the genotype orphenotype with respect to the corresponding reference plasma level inthe case of administration of the dose of parent substance calculated ing), j) calculating a metabolite dose and a parent substance dose for thecombined attainment of the reference plasma level for the metabolitesfrom h) and of the reference plasma level for the parent substance froma), k) outputting the metabolite dose and the parent substance dose forthe fixed-dose combination pharmaceutical formulation via an outputmodule, and/or forwarding the dose calculated in j) into an automateddevice for dosing medicaments.
 2. Method according to claim 1, whereinthe dosage is defined in a genotype- or phenotype-specific manner. 3.Method according to claim 1, wherein the formulation comprises tamoxifenand endoxifen.
 4. Method according to claim 3, wherein the formulationcomprises 15-25 mg of tamoxifen and 0.25-5.0 mg of endoxifen.
 5. Methodaccording to claim 4, wherein the formulation is adapted for CYP2D6 IMpatients and comprises 15-25 mg of tamoxifen and 0.25-2.00 mg ofendoxifen.
 6. Method according to claim 4, wherein the formulation isadapted for CYP2D6 PM patients and comprises 15-25 mg of tamoxifen and1.0-5.0 mg of endoxifen.